Health Care and Emergency Transport Patient

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 Root Cause Analysis It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs death. The questions that follow are pertinent because they set up a scenario with valid questions that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the future. In the case study, it appears that a lack of protocols as well as a lack of communication amongst staff members may have been contributing factors which led to death of a patient in the emergency department. In carrying out a root cause analysis, it is helpful to re-create the event with the staff members integrated in the event. Members of the RCA team observe and question the staff involved. According to (Heitmiller,n.d.). Questions to be answered include:

• What happened?
• Who was involved?
• Where and when did the incident occur?
• Where any policies or procedures involved and were they breached? • What were the conditions of the area involved regarding staffing, availability of equipment, supplies and communication? In the Case study presented Mr B is a 62 year old patient who suffers respiratory distress and dies as a result of the events which preceded his death. Involved in the sentinel event : one RN, one LPN the ER physician. All members provided some form of care at time of incident. The incident occurred in the emergency department at 4:35. The general conditions which transpired were that of a patient who was a stable post hip reduction. Patient had received a total of Diazepam 10 mg, Hydromorphone 4 mg Nurse J placed patient on automatic blood pressure cuff and pulse oximetry. No supplemental oxygen is implemented; no ECG and respirations not monitored post Hydromorphone which was last administered at 4:20. The emergency staff were tending to an emergency transport patient, recently brought in to emergency room in...
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