Organizational Systems and Quality Leadership
Western Governors University
A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome).
“A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ,
2012). The prevention of errors is the main emphasis of a RCA. The process begins with gathering data in regards to the event, then the data needs to be analyzed, and the final step is to find solutions to the errors that were found so that a reoccurrence of the same error doesn’t occur again. The team should …show more content…
B per the scenario is not reevaluated by the RN or MD after the sedation or procedure, as required by policy. The alarm sounds again and Mr. B’s son comes out of the room to notify
Nurse J. Upon arrival she notes that Mr. B’s BP is critically low at 58/30 and his Pox reading is
There is no pulse noted and the patient is not breathing, a code is called for recitation
efforts. The patient when connected to the ECG is found to be in ventricular fibrillation (v-fib).
It takes 30 minutes to obtain a normal heart rhythm, but Mr. B. is intubated and needs the ventilator to breath. Mr.