RTT1 Organizational Systems
Organizational Systems & Quality Leadership
European Governors College or university
A. Root Cause Analysis
A complete root cause examination (RCA) pertaining to Mr. B. is described below. Time of celebration: Thursday, __________ Time of event: 4: 43
Detailed description of event including timeline: Thursday 3: 30 evening Mr. M a 67 year old sufferer was confessed to the ER after a tripping and falling over his dog for his home by doctor J. He was complaining of 10/10 soreness to his left leg and hip region although appears to be in just moderate distress. Mr. B's vital signs were steady at time of admit which has a blood pressure of 120/80, heart rate of 88 and improved respirations of 32. Kept leg can be shortened, enlarged in the shaft, bruising present and limited range of motion to left lower leg. Dr . Big t looked over data and bought Mr. M to have medications for discomfort control and sedation to be able to perform a manual manipulation in realigning Mr. B's dislocated hip. four: 05 nurse J used IV Diazepam per Doctor T's purchases. With no affect Dr . Capital t. orders Doctor J to provide 2mg IVP Dilaudid at 4: 12-15. 4: twenty Dr . Capital t. orders health professional J to provide 2mg IVP Dilaudid for muscular skeletal relaxation. Doctor T. paperwork that every patient's fat and standard usage of Oxycodone, it was so that it is more difficult to own level of sleep required for manual manipulation. 5: 25 Mr. B appears sedated and comfortable and method of manual manipulating the dislocated hip back in place will go successfully and concludes at 4: 35 with the sufferer resting with no signs of distress. Nurse M. places Mr. B with an automatic blood pressure machine and oxygen vividness to go away every five minutes and leaves to take care of an additional patient, with Mr. B's son with the bedside. some: 35 Mister. B's blood pressure is 110/62 and vividness of 92% on area air. The LPN listens to a " low vividness O2” burglar alarm and records Mr. B's saturation is usually 85% area air and repeats blood pressure establishing and resets the security alarm. 4: 43 Mr. B's son alerts Nurse T that the " monitor can be alarming. ” Mr. B's blood pressure browse 58/30 and oxygen vividness was 79% on room air. Sufferer was mentioned to not possess a evidente pulse or perhaps appear to be deep breathing. A STAT code was called, even though the code team begins resuscitative efforts, when hooked to cardiac keep an eye on it demonstrated Mr. B's heart tempo was in ventricular fibrillation. CPR was began by Doctor J and Mr. N was intubated. Mr. N was given reversal medications to reverse the status of Mr. B's sedation, 4 fluids, vasopressors and defibrillated. After half an hour, EKG shows normal sinusitis rhythm with a stable blood pressure of 110/70. Mr. W is still on the ventilator, students are set and dilated, does not respond to painful stimuli and does not have spontaneous actions. Mr. N is airlifted to a tertiary facility pertaining to his care, per relatives wishes. 7 days later, Mister. B was removed from lifestyle support every family request because Mister. B was determined mind dead. Medical diagnosis: Dislocated hip related to a fall, pain to left leg/hip. Medications: Atorvastatin-unknown dosage or perhaps frequency. Oxycodone-unknown dosage or frequency. Previous Medical/Psychiatric Background: No noted drug allergy symptoms. Pasted health background of a sugar intolerance and prostate cancers. Per last visit with Mr. B's principal care doctor, lipids and cholesterol had been elevated. Mister. B happens to be taking Atorvastatin for his elevated fats and bad cholesterol and Oxycodone for Long-term back pain. Current weight 185lbs. Analysis Problem
What was the intended process flow?
Root Cause Research Findings
•" Conscious sedation” per clinic policy requires
•Continuous Blood Pressure readings throughout sedation
•Continuous pulse oximeter throughout sedation
•Continuous Blood pressure, ECG and pulse oximeter must continue until sufferer is able to meet discharge standards, fully conscious and warn, vital indications are secure, no nausea / vomiting and able to void volume sufficient. •All doctors doing " conscious sedation”...