Health Care and Emergency Transport Patient

Root Cause Analysis It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs death. The questions that follow are pertinent because they set up a scenario with valid questions that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the future. In the case study, it appears that a lack of protocols as well as a lack of communication amongst staff members may have been contributing factors which led to death of a patient in the emergency department. In carrying out a root cause analysis, it is helpful to re-create the event with the staff members integrated in the event. Members of the RCA team observe and question the staff involved. According to (Heitmiller,n.d.). Questions to be answered include:

• What happened?
• Who was involved?
• Where and when did the incident occur?
• Where any policies or procedures involved and were they breached? • What were the conditions of the area involved regarding staffing, availability of equipment, supplies and communication? In the Case study presented Mr B is a 62 year old patient who suffers respiratory distress and dies as a result of the events which preceded his death. Involved in the sentinel event : one RN, one LPN the ER physician. All members provided some form of care at time of incident. The incident occurred in the emergency department at 4:35. The general conditions which transpired were that of a patient who was a stable post hip reduction. Patient had received a total of Diazepam 10 mg, Hydromorphone 4 mg Nurse J placed patient on automatic blood pressure cuff and pulse oximetry. No supplemental oxygen is implemented; no ECG and respirations not monitored post Hydromorphone which was last administered at 4:20. The emergency staff were tending to an emergency transport patient, recently brought in to emergency room in respiratory distress. A protocol for care was not implemented post narcotic administration, patient was sedated and close monitoring of ECG and respirations were not standard of care.

Change Theory

According to (Mitchell,2013)change theories are similar problem-solving approaches to implementing planned change. In the incident of Mr. B. following change theory is utilized practicing Lappets theory.

Nurse B makes a detailed assessment of the Mr. B that includes biographical details, relevant clinical history, social details and medical observations. This phase is normally taken into consideration throughout a patient’s hospital stay.

Following assessment, the nurse b collaborates with the patient, significant other or family member and multidisciplinary team wherever possible to determine how to address the needs of the patient.

This phase relates to the nurse carrying out and documenting the care previously greed at the planning stage. Post administration of sedations followed by a protocol which would closely monitor patients vital signs. Nurse B continues to monitor the patient throughout the emergency room visit shift. The vital signs are monitored every 15 minutes and documented. Parameters are set instituting intervention if pulse oxygenation falls below 95%. 

The evaluation phase all interdisciplinary team members and their part in the interaction of patient care. Assessments graded for what worked well and where work still needed for improvement.

Failure Mode and Effects analysis

The multidisciplinary team included in the (FMEA) and RCA are the secretary, RN , LPN, respiratory therapist and the Emergency room physician. In order
to evaluate interventions set forth to improve care documentation of what could go wrong , why would the failure happen and thirdly would be the consequences of such failure. Staffing was a factor as there was only one RN staffed in a critical setting. Chart audits would be instituted to identify documentation is complete. Shift start will include monitor checks to assess that monitor alarms are functioning appropriate. FMEA is a great tool to be used in risk analysis and quality control, its use proactively evaluates health care processes. The FMEA steps are: Step One: Select a process to evaluate with FMEA.

Step Two: Recruit the Multidisciplinary team. Team is anyone who comes in contact with patient. Step Three: Team to meet to discuss the steps in the process. Presteps for preparing for the FMEA are evaluating subgroups, identify a potential issue and identify members in the multidisciplinary group that will institute the process. As noted in (Wikipedia, n.d.) Severity classification is assigned for each failure mode of each unique item and entered on the FMECA matrix, based upon system level consequences. A small set of classifications, usually having 3 to 10 severity levels, is used. Occurrence is rated on scale of 1 through 10 where one is unlikely and 10 is highly inevitable Detection is obvious hazard that there is something wrong with the system.FMEA implements a proactive approach to avoid such hazards from occurring and utilizes the multidisciplinary team approach. Nurses play a key role in the integration of patients throughout the healthcare system. Patient’s first encounters in the hospital setting are usually the nurse triaging the patient through the departments. As nurses assess patient’s needs. It is the nurses’ duty to perform rapid thorough assessments. These assessment skills come in several triers. There is the Novice nurse, practicing on nursing principals. An experienced nurse does without thinking simply completely tasks base on clinical experience. This nurse feels that nursing professionals are patient advocates, and clinical liaisons, assisting their patients as they progress through the healthcare setting. In review of the case study the dosage of hydromorphone is one which an experienced nurse may question. Triaging the patient to the LPN for one on one care while patient recovering from the Valium and Hydromorphone is one intervention. protocol documenting close monitoring of
respiratory rate secondary to the narcotic being a respiratory depressant can be instituted. A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. (Wikipedia)

According to (Pettinicchi,2005) many incidents of patient harm have been traced back to care delivery systems that predispose health care providers to make errors. The national patient-safety goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are aimed at helping facilities correct system shortcomings, prevent problems, and lower the risk of errors.


Heitmiller,E . (n.d.) Lecture on The Root cause analysis in response to a sentinel event. Personal collection of E,Heitmiller, Johns Hopkins University School of Medicine, Baltimore, MD Mitchell, G. (2013) ‘Selecting the best theory to implement planned change’, Nursing Management, 20, (1), pp. 32-37. Pettinicchi,T.Nursing August 2005-Volume 35 Issue 8-p 24-26 Article Wikipedia.(n.d.). Retrieved from Sentinel Event Wikipedia.(n.d.). Retrieved from,_effects,_and_criticality_analysis

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