Nurse J was distracted by another patient and the increasing census in the ER

Nurse j was distracted by another patient and the

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but did not follow. Nurse J was distracted by another patient and the increasing census in the ER. Although there was additional back up staff available that day, they were not called on to help. When the O2 alarm went off the LPN just shut it off without checking or responding to the declining O2 saturation. She should have placed the patient on O2 if ordered or at the very least notified the RN immediately. The patient should have been on continuous ECG monitoring per hospital policy and the LPN should have stayed at the bedside. Although the patient had a history of taking oxycodone, the combination of hydromorphone and Diazepam IV together with this patients age puts him at a much higher risk of respiratory depression and he should have been monitored closely. Dr. T should have been notified on a regular basis of the patient’s status. B. Improvement Plan
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Running head: Task 2 Root Cause Analysis Implementing an improvement plan would reduce the likelihood that this adverse event would reoccur. In this case, following the hospital conscious sedation policy would be a priority. Although Nurse J finished the module, the hospital should implement a mandatory annual review with a post-test. Having a staffing ratio plan based on acuity is also necessary. Additionally, the conscious sedation policy should include 1:1 staffing during the procedure and recovery phase. Placing the patient on conscious sedation precautions with signage by the bedside and a check list to be filled out and followed at designated time intervals would be appropriate. If this is not possible then having patients on visual monitors as well as ECG and O2 monitors with a licensed nurse stationed at a central monitoring location at all times would be another option. It’s also essential to educate the LPN and ancillary staff on the alarm systems and specific tasks as well as when to report abnormal findings immediately. B1. Change Theory Kurt Lewin’s theory of change incorporates human behavior into the change management process. It consists of 3 steps: unfreezing, change and refreezing. 1. Unfreezing: This initial step focusses on helping people become less attached to what they’re used to thinking or doing so that they can become open minded about trying something different or new. Healthcare is constantly changing and evolving which requires the ability to constantly analyze processes and be willing to change as it evolves. Having rigidity is not always appropriate for every situation. In the case of the scenario presented in the ER, the staffing may have been appropriate early in the shift for the number of patients but as the acuity increased, the ER needed more nurses to help manage the patients safely. It’s important to keep staff budgeting in mind but patient safety should always come first. When applying Lewin’s theory to this situation, being
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Running head: Task 2 Root Cause Analysis able to look beyond the budget or unfreezing a fixed staff patient ratio protocol to provide
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  • Fall '18
  • Root cause analysis

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