A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) …show more content…
by Nurse J. After five minutes, the diazepam had no effect so Dr.T ordered two milligrams of hydromorphone IVP given at 4:15 in the afternoon. The patient received another two milligrams of hydromorphone IVP and five milligrams diazepam IVP at 4:20 p.m. because Dr.T was not satisfied with the patient’s level of sedation. When the patient appeared to be sedated at 4:25 in the afternoon, the reduction of his left hip took place. At 4:35 p.m., Mr. B’s BP is 110/62 and his oxygen saturation is 92%. The “conscious sedation” policy was not followed. He did not have supplemental oxygen and his ECG and RR were not monitored. Then, Mr.B’s oxygen saturation dropped to 85%. The LPN adjusted the alarm and repeated the BP reading. Nurse J and the LPN were very busy taking care of the other patients during this time. At 4:43 p.m., Mr. B was not breathing, had no pulse, BP is 58/30 and oxygen saturation is 79%. The stat code was called. The third step of root cause analysis process is identifying possible causal factors (Mind Tools, n.d.). In this step, the team would determine the factors that contributed to the event. In the given scenario, the factors that led to Mr.B’s sentinel event were his tolerance to pain medications and clinical situation (age, weight, and kidney function) were not considered. The emergency department was very busy and understaffed which caused Nurse J to leave the room and unable to monitor the patient closely. Another factor was that the
Take each bag of popped popcorn and count the individual kernels that did not pop and record the data on the chart. Perform this for each
mitigate these points assessments will be made in how to best mitigate the failure and what would need to be done to
6. Many drug safety research studies are sponsored by pharmaceutical companies that would financially benefit if the results of the study are favorable. Is this an example of a potential confounding factor?
But for another example a pizza shop in competition wit a fried chicken shop would be indirect because the products are not the same but they are still competing for sales.
Presentation regarding the university’s Disaster Recovery Plan/Enterprise Continuity Plan including: basic structures; roles within the DRP/ECP plan; areas within a company if addressed improve resilience to catastrophic events, and an employee awareness campaign.
This assignment will look at incidents and emergencies that can happen in a health and social care setting. Within my assignment I will be explaining possible priorities and responses when dealing with two incidents or emergencies in a health and social care setting. I will be discussing
The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from
This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.
Chosen for root cause analysis is case study number 18, titled “Not for IV Use: The Story of an Enteral Tubing Misconnection” from the book Case Studies in Patient Safety: Foundations for Core Competencies. Root cause analysis is a process whereby error producing system factors are identified and reviewed to assist in the formatting and implementation of solutions to prevent similar errors from reoccurrence (Wachter, 2012). This accounting of the patient’s experience located in the Systems-Based Practice (SBP) section also highlights various code of ethics violations such as autonomy, beneficence, nonmalfeasance, and veracity. The SBP approach in healthcare requires that personnel recognize how patient care connects to the entire health care system and how to utilize successfully system resources to improve both quality and patient safety. There are specific core competencies that assist with this process. Some of which include the ability to work effectively in the delivery-care setting, perform responsibilities according to role, ability, and qualification, advocate for quality patient care and resources, and participate in error identification and solution implementation (Johnson, Haskell, & Branch, 2016). This patient’s story demonstrates an apparent failure of these core competencies.
The root cause analysis, RCA is used in the health care profession to find flaws and opportunities for improvement in the nursing environment. It is a structured analysis method for serious adverse health care events. Moreover, by conducting a RCA, health care practitioners determine the underlying problems that intensify the likelihood of errors with avoidance of focus on individuals’ mistakes. A systems approach is used to detect and eliminate active and latent errors to prevent future harm. As a result, RCAs follow a pre-specified protocol starting with collection of data, record reviewing and participant interviews to reconstruct the event in question (Franklin, Shebl & Barber, 2012).
1. Describe how you've used media over the last few days in these four areas: cognition, diversion, social utility, and withdrawal. Now describe how the media has helped you during this same period in terms of: surveillance, interpretation, linkage, entertainment, and formulating values.
Incident reporting is important to understand so that the health and safety of the abused or injured is preserved and the acts are stopped. Incident reports are different in every facility and this document goes to the person responsible for investigating the incident and not in the chart. Failing to report can end in civil and/or criminal charges with monetary retribution attached. Sentinel events are important to understand so that the Joint Commission or other governing entity knows about the event so that it can be stopped, investigated or changes can be made so that the event does not happen again or to anyone else. Root cause analysis is the underlying cause of the event, the processes of the event from beginning to the end so that overall
The school affirmations process is a long one, most vital parts are, the SAT or ACT state-sanctioned test, and one can profit by early arranging and choosing while amid secondary school you should take it and the particular test dates. Additionally, consider conditions like individual schedule,r confirmations due dates, the selection of subjects in school to take the SAT or ACT.
Patient XX is a 50-year-old female admitted to the acute care unit for a GI bleed and is being treated for alcohol withdrawal as well. Her vital signs are; Blood pressure of 117/62 taken in a lying position on the left arm with an automatic cuff, a temperature of 97.2 degrees Fahrenheit taken in the left ear with the tympanic thermometer, a pulse of 68 taken radially on the right arm while in the lying position, a respiration rate of 16 while the patient was lying down, and an oxygen saturation of 99% taken on the right index finger. She states that she feels much better today and she was happy she can finally eat normal food without it hurting her stomach.