Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis The purpose of this root cause analysis is to carefully examine the causative factors, errors, and hazards that led to the sentinel event of Mr. B’s death. Mr. B was 67 year old male that presented to the ED with his son and neighbor. Mr. B stated that he tripped and fell over his dog. Upon assessment Mr. B’s vital signs were stable with the exception of rapid respirations, his left leg was shortened, red and swollen, and pain was rated 10 on 1-10 scale. The first step to a root cause analysis is to identify what happened. In this scenario, the patient is admitted to an ED room after proper triage. Initially, 5 mg diazepam was ordered by the ED Doctor, and administered by Nurse J at 4:05 pm. After five minutes, no status change is noted and Dr. T ordered 2 mg hydromorphone IVP. This is administered at 4:15 pm. Dr. T then ordered an additional 2 mg hydromorphone IVP, as well as an additional 5 mg diazepam IVP. At 4:25 pm a successful reduction of left hip takes place. At 4:30 the procedure is concluded. The patient remained sedated, showing no signs of distress or discomfort. Mr. B is not currently on supplemental oxygen. Mr. B is placed on an automatic blood pressure machine programmed to monitor the blood pressure every five minutes as well as a pulse oximeter. At 4:35 pm Mr. B blood pressure is 110/62 and O2 saturation is 92%. He has no supplemental oxygen, and his ECG and respirations are not monitored. Nurse J and the LPN receive a new patient in respiratory distress, are discharging two patients, and the ED lobby is getting increasingly busy.