Rtt1 Task1

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Organizational Systems and Quality Leadership Task 2

Western Governors University
03/15/2015

Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem, would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point of start till the end of the given service in order to detect the safety risk factors. In the given scenario, root cause analysis technique will be used to detect the errors that happened during the emergency department admission of Mr. B who with the chief complain of severe left leg and hip pain secondary to fall. A. Root Cause Analysis

“The Joint Commission requires that organizations conduct a root-cause analysis to identify contributing factors within 45 days of a sentinel event or becoming aware of the event. This analysis focuses on systems and processes, not individual performance. All persons involved with the event in any way should participate in the analysis, as each may have important insights and observations.” Sorbello, B. (2008, October 11 ) According to the mentioned Scenario Mr. B, a sixty-seven-year old gentleman,who admitted to Emergency department with stable blood pressure and heart rate and excrutiating pain of the Left leg and Hip area. Based on the given scenario patient received extra doses of sedating receiving all the administered pain medications given to patient had a side effect of respiratory rate slow down and respiratory distress and failure. Furthermore, the amount of given medication was not followed by hospital protocol. Furthermore, after manual procedure of Left leg and hip relocation, there was no given order of Supplemental oxygen for the patient prior and after procedure and no EKG monitoring of the heart was mentioned throughout the scenario. Even though MD ordered continues monitoring of patient’s oxygenation status and the blood pressure level status , but there were no orders to monitor respiratory rate status.The other error during the scenario is the knowledge defecit level of the LPN, whom just scilenced the alarm for the oxygen saturation level in patient’s room without any further discusions or informing of assigned RN. On the other hand, the other factor of care failure was the ER department under staff situation which ended to ill-treatment of Mr.B. B:

The change of the following scenario to prevent the sentinel event occurrences would be for the ER staff to follow up hospital protocol regarding the sedation. Secondly, Health care staff must have monitored patients vital signs status from admission to the discharge point. LPN should have proper understanding of signs and symptoms of respiratory status post conscious sedation procedures, knowledge regarding sedative medication side effect and the adverse reactions and how to respond accordingly to such adverse reactions. Furthermore, there should be a proper communication among the healthcare providers for ultimate care outcomes. During conscious sedation procedure, there should have been constant checking and reassessing the cardiac and respiratory status of the patient by the staff. Additionally, During the work shift there should be acceptable number of float nurses in the emergency department to provide care during the shift.

Outcome Measure:
What are the factors that will be considered, monitored, observed, supervised, and verified? Proper and sufficient training of health care staff based on protocols and policies of the hospital agreement, in emergency department. How the cases will be monitored and the patient’s charts and tests and lab results and plans will be accompanied? The monitoring and observation for the period of three months, in order to achieve...
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