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Mr B Root Cause

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RTT1 Organizational Systems Task 2
The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care in the Mr. B scenario will be discussed.
A. Root Cause Analysis
A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). The participants during the root cause analysis would be the emergency room physician (Dr. T.), the Mr. B’s LPN and RN (Nurse J) during the time of the sentinel event, the emergency room nurse manager, and the chief nursing officer (CNO) of the hospital. These members would meet in a root cause analysis meeting to discuss the causative factors that created Mr. B’s sentinel event. The first step in a root cause analysis on the sentinel event that caused Mr. B’s death is to gather the data surrounding the situation. Mr. B’s vital signs, including his blood pressures, important laboratory values, pain scores, and history of medication dispensed during the situation must be collected. The second step in a RCA is to describe the facts of Mr. B’s sentinel event. The third step in a RCA on Mr. B’s sentinel event is to ask why each of the...

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