п»їA Root Cause Evaluation
Western Governors University
Author Be aware
Organizational Devices and Top quality Leadership (RTT1) A Cause Analysis
Health care facilities that are accredited by Joint Commission payment are required after a sentinel celebration to carry out a cause analysis (RCA). A cause analysis is conducted to determine the cause or factors that contributed to the sentinel celebration. A few points must be asked in the RCA such as whom, what, exactly where, why and exactly how in order to recognize the cause. Following the cause of the sentinel event is determined and a corrective action plan have been put in place an inability mode and effects examination (FMEA) could possibly be conducted to minimize the likelihood which it should happen once again. The scenario
A 67 year old man (Mr. B) was generated within the emergency room for soreness to still left leg and left hip. The personal injury occurred if the patient had a fall because of him shedding his harmony after tripping over his dog. A healthcare facility is a 60 bed non-urban hospital positioned in Mr. B's hometown. Mr. B was brought in by his boy and neighbor. Upon choix Mr. N was complaining of soreness 10/10 around the numerical discomfort scale and his vitals had been found to become stable. Mr. B contains a history of disadvantaged glucose threshold, prostate tumor, and chronic pain which in turn he is upon oxycodone. The individual states he had no known allergies or perhaps previous declines. Upon the nursing evaluation Nurse L. has pointed out that the patient has limited range in motion, his left lower-leg has puffiness and looks shortened compared to the right. Registered nurse J. provides informed the ED physician which this individual came to his bedside intended for evaluation. Upon evaluation the physician decided that Mr. B necessary to have a reduction of his left hip, due to the dislocation and will demand a conscious sleep. Mr. W requires multiple doses of medication to achieve the desired sleep affect for the lowering. Once the reduction was powerful Mr. W is playing son in the room where a total set of fondamental were not continually monitored and goes into respiratory failure which will lead to the death of Mr. B. Staffing within this day is definitely the day of the event contained a admin, emergency division physician (Dr. T), and two nursing staff (one RN and one particular LPN). A respiratory specialist is in property and offered as needed in this six bed EDUCATION and 59 bed clinic.
At three or more: 30pm- Mr. B was taken to ED for remaining leg and left hip pain via a fall. Discomfort is a 10/10 vitals include 120/80 stress (BP), 88 heart rate (HR) and regular, 98. six temperature, (T), 32 respirations (R), a hundred seventy five lbs.. For 4: 05pm- Mr. M was given Diazepam 5mg IVP which had no influence after 5min. At four: 10pm- Dr . T orders 2mg of hydromorphone to become given to Mister. B. In 4: 15pm- Mr. B was given 2mg of hydromorphone IVP.
At 5: 20pm- Dr . T is not satisfied with level of sedation and instructions Mr. B to be given 2mg of hydromorphone, and diazepam 5mg IVP. At 4: 25pm- Mr. N appears to be sedated and reduction of his (L) hip takes place. The patient remains sedated and appears to have tolerated the procedure. The procedures concludes at four: 30pm. No distress is usually noted, sufferer is placed in monitor for blood pressure to be taken every 5 minutes along with pulse oximeter but simply no supplemental oxygen or ECG leads (monitors cardiac rhythm and respirations) was placed on patient at the moment. At four: 30pm- Nurse J allows Mr. B's son to keep in the room with him as he is being monitor by blood pressure machine only. Nurse J leaves the room. At 5: 35pm- Mister. B essentiel are BP 110/62, UNITED KINGDOM sat can be 92% even now no o2 or ECG leads are on patient currently. EMS is transporting someone in breathing distress, reception is beginning get overloaded. LPN and Nurse J. in the process of discharging two patients and they are checking inside the patient that EMS provides transported in. LPN makes its way into Mr. B's room and resets his alarming screen that was showing a sat of 85% and restarts the B/P to recycle. LPN does not source oxygen and does not alert Health professional J currently....
References: Office of Security Patient Protection Center. (2004, 12 26). Failure Function and Results Analysis. Gathered from FMEA Info Hub: http://www.fmeainfocentre.com/handbooks/FMEA_Guide_V1.pdf
Institute for Heathcare Improvement. (2004). Failure Methods and Effects Analysis (FMEA). Retrieved coming from Institute for Heathcare Improvement: http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
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