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C489 Task 2

In: Business and Management

Submitted By hmd24
Words 2622
Pages 11
The Unfortunate Hospital Experience for Mr. B

Identification of Events

* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam * Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation * Dr. T orders additional sedation medication * 2mg of Hydromorphone * Nurse J administers additional sedation medication per Dr. T orders * Mr. B is not fully sedated and Dr. T orders a 3rd dose of sedation medication * 5 mg of Diazepam and 2 mg of Hydromorphone * Dr. T assesses Mr. B. * Mr. B is fully sedated for the procedure * Dr. T reduces and sets Mr. B’s left hip * Mr. B’s procedure is completed. He appears comfortable and remains sedated * The Emergency Room receives an emergency dispatch call * Pt. in respiratory distress * Nurse J needs to respond to the call. * Nurse J puts a blood pressure cuff on Mr. B with 5 minute cycles and places the pulse oximeter on Mr. B * Son remains at bedside * Nurse J leaves the room to care for the patient in respiratory distress * Mr. B’s pulse oximeter alarm goes off “ low O2 “ * LPN responds to the alarm. LPN disables the alarm, recycles the BP machine and leaves room * Mr. B’s son locates Nurse J and states the machine keeps alarming * Nurse J responds and assesses Mr. B * Mr. B is pulseless and not breathing * Code Blue is called * Mr. B is subsequently found to be in V fib arrest. * Required defibrillation and intubation...

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Wgu Org Sys2Tems Paper 2

...C489-Task 2-revised version Gina Potter 000203903 Western Governor’s University January 31, 2016, 2016 The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be used to project the likelihood that the suggested improvement plan would not fail.  In conclusion key roles of the nurses involved in the care in the Mr. B scenario will be discussed. I have completed the RCA considering: causative factors, errors and hazards that had unfortunately lead to the death of the 67 year old patient that was brought to the ED. By performing the RCA we start at the beginning with the causative factors, we list staffing levels, who was there and who was not. The participants during the root cause analysis would be the emergency room physician (Dr. T.), the LPN and RN (Nurse J) the respiratory therapist who was in house but not in the ED at the time of this sentinel event, and the unit secretary....

Words: 4483 - Pages: 18