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Organizational Systems and Quality Leadership

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Organizational Systems and Quality Leadership Task 2

Mark Woodard

Western Governors University

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.

Root Cause Analysis

A root cause analysis, is a system that is used to develop a plan that will identifying the causative factors of an adverse event and formulate a plan to decrease the occurrence or chances of a sentinel event. A team consisting of , a member of the hospital administration, a pharmacist, a respiratory therapist, a charge nurse or nurse manager, a physician, and a member of the family board should be brought together to perform a root cause analysis in this case. These team members would have a meeting to discuss the factors that led to Mr. B’s sentinel event. The first step would be for the team to begin interviewing the staff involved with the case to gather as much data as possible. The data that would be needed include, Mr. B’s vital signs, laboratory results, pain scores, a history of medication that he was given during his time in the emergency room in addition to any home medications, and the monitoring that was performed by the nursing staff after he received the medication. Some causative factors that could have led to Mr. B’s sentinel event are, his tolerance to opiates, his clinical condition, the lack of

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