Open in a separate window Once alarms are triggered, most hospitals today have organizational rescue processes in place to deal with them. These commonly involve some variation on a rapid response team RRT activation that behaves like a "fire brigade" coming to the rescue of the patient in trouble [ 34 ].
Get Full Essay Get access to this section to get all help you need with your essay and educational issues. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame Agency for Healthcare Research and Quality, It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety.
The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the adverse event Connelly, Additionally a review of the patient record along with interviews of the personnel involved provides valuable insight into how the patient care processes broke down.
Hospitals are complex organizations that have many layers of safety erected to protect the patient from action taken by healthcare providers.
These safety measures include policies, protocols, and guidelines. The reason for multiple layers, or measures, is that there can be weaknesses in the process that forms an opening for an error to occur Elliott, Page, and Worrall-Carter, The fundamental goal of the RCA is to prevent future patients from being harmed through understanding how an adverse event could occur.
Root Cause Analysis We are examining the events surrounding the treatment of Mr. B in the emergency department for a dislocated left shoulder. B was brought to the hospital by his son and taken by Nurse J to an examination room to obtain a health history and physical assessment.
Important facts to know are: His past medical history included: Most recently his primary care physician noted his cholesterol and lipids were elevated.
B and the decision was made to relocate the shoulder using moderate sedation. The shoulder was successfully reduced at hours and Mr. B tolerated it well. At hours Mr. Nurse J finds Mr.
B was transferred to a tertiary care facility for advanced care but after seven days it was determined that he suffered brain death. The family decided to remove life-support and Mr.
The root cause analysis will ask several questions in order to identify the cause, or underlying causes, that contributed to the occurrence of an adverse event. The decision was made to perform a closed reduction of the shoulder with moderate sedation.
There is a policy for moderate sedation that requires the patient be continuously monitored throughout the procedure and until discharge criteria are met.
As stated in the policy, continuous monitoring includes blood pressure, ECG, and pulse oximetry; the ECG monitoring would give evidence of respiratory rate and effort.
The discharge criteria in the policy states the patient will be fully awake, vital signs stable, no nausea or vomiting, and the patient is able to void. All practitioners that provide moderate sedation must complete a training module prior to providing moderate sedation, this includes personnel assisting with the procedure.Root Cause Analysis of a Sentinel Event Essay Sample A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes.
The aim of this assignment is to conduct a root cause analysis of Mr. B. The patient, Mr.
B. arrived at the emergency room with a dislocated left shoulder after a fall in the shower.
The medical practitioner put him through moderate sedation and relocated the shoulder. A Root Cause Analysis Western Governors University Author Note Organizational Systems and Quality Leadership (RTT1) A Root Cause Analysis Healthcare facilities that are accredited by Joint Commission are required after a sentinel event to conduct a root cause analysis (RCA).
Moderate Sedation Study Aid This colorful graphic summary includes key elements of moderate sedation practice, including many of the topics from the curriculum guide. This by inch front and back reference guide may be posted for practitioners in all sites where moderate sedation is .
A root cause analysis is conducted to determine the cause or factors that contributed to the sentinel event. A few things must be asked in the RCA such as who, what, where, why and how in order to identify the cause.
Within 10 days the conscious sedation procedure should be evaluated by a committee to ensure the best practices are being. Root Cause Analysis And Conscious Sedation ROOT CAUSE ANALYSIS OF A SENTINEL EVENT Diane Swintek Western Governors University Root Cause Analysis of a Sentinel Event A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or.