Task 2

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RTT Task 2
Western Governors University

Sentinel events are never something healthcare workers or facilities want to have occur. If an unfortunate event does take place, it is necessary to properly investigate the situation in hopes to learn from the event and hinder another episode. The following will discuss procedures used to investigate sentinel events such as root cause analysis, change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions. A. Root Cause Analysis

Nursing is a profession of helping others. Those who choose to work in healthcare never intended on harming. However, if harm does come to a patient proper policy and procedure should be followed after the event. “The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adversed events improve safety and learn from those sentinel events” ("Sentinel Event | Joint Commission," n.d.). The intention of the root cause analysis is to find the areas in need of improvement for reduction of risk and aid in better patient care.

Mr. B arrived in the Emergency Department with left leg and hip pain. After assessment it was determined Mr. B would undergo left hip reduction under conscious sedation. Mr. B was sedated appropriately with successful reduction. Nurse J and the LPN on staff had no signs of personal issues which led to the adverse event however there was a lack

of complex critical thinking skills by both staff members. To begin, Nurse J was following Dr. T’s orders with medication administration. Mr. B’s medical history was reviewed and it was found Mr. B took oxycodone on a regular basis. With the additional IV medication there should have been concern of respiratory depression due to the multiple pain medications administered. This respiratory depression was evident when the LPN entered Mr. B’s room and found his oxygen saturation alarm sounding. Unfortunately, the LPN did not notify either Nurse J or Dr. T of Mr. B’s oxygen saturation of 85%.

The equipment used in Mr. B’s care was found to be in working order. It is not clear if the LPN understood the warnings and alarms since there was no further interventions completed when Mr. B’s oxygen saturation alarm sounded.

There were no uncontrollable external factors such as a natural disaster that added to this event. There was an influx of patients in Emergency Department lobby with the added stress of an anticipated emergency transport patient.

Not having more information regarding the hospitals abilities, unsure if this event could have occurred in other areas of the facility.
The hospital had policy in place for conscious sedation and Nurse J had completed the training module for conscious sedation as well as holding a current ACLS certification. Nurse J was an experienced critical

care nurse with clinical evaluations showing she met the requirements of her position. The credentials and training of the LPN on staff is unknown.
Staffing at the time of the event consisted of one RN, one LPN, one secretary and one Emergency Department physician. Respiratory Therapy is on staff, not present, but available if needed. When Mr. B arrived he made the third patient in a six bed Emergency Department. Additional back-up staff was available if needed. Policy for nurse to patient ratio for the facility is unknown however one on one care should have been addressed with the potential for respiratory depression with Mr. B. Additional staff were available to care for the incoming patients but were not utilized. With the issue of one on one care for conscious sedation if the only concern was respiratory related the in-house respiratory therapist could have been paged to monitor Mr. B while Nurse J was caring for other patients. Knowing Mr. B’s medication history of oxycodone use for chronic pain and the added medication for sedation would most...
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