Why was Mr Bs weight and home medications ignored when choosing sedation

Why was mr bs weight and home medications ignored

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the moderate sedation policy not followed? Why was Mr. B’s weight and home medications ignored when choosing sedation medications? Why was additional staff not called down to the emergency department to help with the surge? Why was Mr. B not on supplemental oxygen when receiving sedatives? Why were alarms ignored? Why was CPR not started immediately upon discovery of a pulseless patient? There are a couple of causal statements that can be made for this sentinel event. For one, the hospital’s moderate sedation policy was not followed, which led to the patient not being sufficiently monitored, which caused his eventual death. Secondly, the nurse did not immediately begin CPR despite being ACLS certified, which led to a delay in cerebral perfusion, which ultimately caused irreversible brain death in Mr. B. B. Improvement Plan There are a few things I would propose outright for a process improvement plan in order to decrease the possibility of a reoccurrence of this tragic sentinel event. These actions include the following: 1. Improve Staff Education on Moderate Sedation Policy – Develop an interactive module on the moderate sedation policy and procedure, which all staff will be required to complete annually moving forward. 2. Improve Patient Safety During Sedation Recovery – In order to ensure safe recovery from sedation, any patient that is sedated must be continuously observed by an RN 1:1 until they return to their baseline mental status pre-sedation.
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Running head: Organizational Systems Task 2 6 3. Improve Sedation Protocol – Develop cognitive aids/standard protocols like check lists in the electronic health record for pre, intra, and post sedation setup, to include things like vitals/monitoring, checks to ensure all equipment is available, proper monitoring is occurring, and positive outcomes are achieved. By implementing these actions, the sedations in the emergency department would be more standardized, and much safer. Keeping an RN with a recovering patient is a must, as is appropriate monitoring, protocols, and education. B1. Change Theory Kurt Lewin's Change Theory proposed that change occurs in three phases: unfreezing, change, and freezing. The first step involves helping others to see why a specific change is needed, and how it will be accomplished, thus "unfreezing" them from their current practice (Institute for Healthcare Improvement, 2016). This phase could be applied to the proposed improvement plan by briefly discussing the sentinel event in a daily huddle with all employees, how it occurred, what changes we’d be implementing, and how we would go about doing so. The second step is where change occurs and is a period where some individuals may have a difficult time if they are affected by it. During this phase, the actual education would be rolling out, along with new staffing guidelines, and new checks/procedures within the electronic medical records.
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  • Spring '19
  • Failure mode and effects analysis, RCA, Mr. B, Nurse J

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