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given which led to Mr. B to have respiratory depression, which caused his blood pressure to drop, which led to Mr. B dying. This happened because 5)Generate a list of recommended actions to prevent the recurrence of the event:This is a list the team comes up with to prevent an event like this from happening again. The recommendations that the team comes up with will fall into a strong, intermediate or weak action. A strong action “is likely to eliminate or greatly reduce the likelihood of an event. An intermediate action is likely to control the root cause or vulnerability. A weak action by itself is less likely to be effective.” ("IHI RCA summary sheet," n.d., p. 2) Thereare many specific categories that will help prevent the event from happening again which include: standardizing equipment, double checking or using backup systems, and educating staff. ("IHI RCA summary sheet," n.d.)Scenario:A couple of examples are: Education for the entire hospital on conscious sedation and monitoring after conscious sedation. Create a standard checklist with height/weight of patient and waiting times to allow the medications to work.
C489 SAT TASK 266)Write a summary and share it:This can be the most important step, to me, because by sharing the event we can all learn from it and ensure that something like this doesn’t happen again.Scenario:Create a document with all the above information with what is planned to ensure this doesn’t happen again and share it with the hospital.Process ImprovementProcess improvement or quality improvement plan is a plan for enhancing safety, effectiveness and efficiency, and monitoring, assessing and improving the standards of quality healthcare. ("Quality improvement in healthcare," 2016) For this scenario I wouldrecommend Conscious Sedation education for all RNs and MDs, as well as respiratory therapists. The course would emphasize the importance of monitoring patient’s vitals after the procedure. If staff isn’t available, then there needs to be someone on call to come in a do that. In this case the respiratory therapist could have come down and monitored Mr. B. Lewin’s Change TheoryB) Lewin’s change theory has 3 major concepts Unfreezing, Change and Refreezing. Unfreezingis a way of letting go of a routine, change is moving to a new level and refreezing is creating a new habit. ("Lewin’s change theory," n.d.) The employees of the hospital may not like being retrained on something they think they know about but when it is put in perspective about a person’s life or death, and it is pointed out what happened because the guidelines weren’t followed they will see that change is what is right. They will need to 1) unfreeze – change the
C489 SAT TASK 27way they see conscious sedation, 2) change – reprogram how they think about conscious sedation – even if it takes more time in the long run – and 3) refreeze – see that it is time well spent if no patient dies.