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The final step is writing a summary of the whole event. The team summarizes the happenings in the order they occurred by a simple diagram like a flow chart. The summary is then presented to the key players who will help in improvements.Application of the RCA process in our case study.Identification of what happened. Mr. B arrives in hospital at 3:30 p.m. complaining of leg and hip pain. He is admitted with vital signs of B.P 120/80, HR-88,T-98.6,R-32 and weighs 175 pounds. His rate pain was at 10 out of 10.Nurse J examines Mr. B’s medical history snd gives thefindings to the Dr. T. After Dr. T examining Mr. B, he gives Nurse J. instructions on administering sedative on Mr. B. He is given four dozes of two different sedatives within a span of fifteen minutes. At 4:25 p.m. he is sedated and successful reduction of his hip takes place. At 4:30 Nurse J leaves to attend to another patient and leaves Mr. B in a stable condition. At 4.35 hisB/P is at 110/62 and oxygen saturation is at 92% under no supplemental oxygen or respiration monitoring. His oxygen alarm is heard and it reads “low saturation”. The LPN comes and resets the alarm and repeats the B/P reading. At 4:35 Nurse J is called by son and finds Mr. B not breathing. STAT code is called and resuscitative efforts are made on him. After thirty minutes, his B/P stabilizes but he is now dependent on the ventilator. Mr. B is then airlifted to a tertiary facility where he is diagnosed with brain death.7 days later, he passes on after life support machine being removed.What should have happened? Mr. B should have been given special attention throughout. He should have been put under supplemental oxygen and under respiration monitoring. A Nurse should have been with him throughout. When the LPN came to check on him when the oxygen alarm rang, he should have dealt with it as an emergency case.
Running Head: RCA AND FMEA4Determining the causes of the event. There was less staff that day and patients were many. The