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Root Cause Analysis

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Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten. The professionals involved in the root cause analysis would take on roles. The team leader would be a representative from risk management. The nursing supervisor that was working on the day of the event would be the recorder. The team members would include the manager of the emergency department, the RN, LPN, and physician involved with the patient from the emergency department. The advisor would be the chief nursing officer or another member of the executive staff. The first thing is to review the many causative factors that were in place on this particular day. There was inadequate staffing for the emergency department for the number and high acuity of patients that were being treated. There was a hospital protocol for conscious sedation that was not followed. The nurse was ACLS and CPR certified. The patient was not fully monitored for the procedure. This would require Mr. B’s level of consciousness, blood pressure and respiratory status to be continuously monitored. There was no supplemental oxygen provided for the patient nor was his ECG being monitored. A large amount of narcotics and sedatives were used on Mr. B considering his weight and age. The LPN

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