RTT1 TASK 2 100 % OKAY

RTT1 Task 2 Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them. A. Root Cause Analysis “A central tenet of 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 emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not involved in the case is assembled to work through the process. The team begins by interviewing patients and staff involved to gather as much vital information as possible. Once all necessary information is compiled, the team works together to get to the root(s) of the problem. In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one root problem. In the process of defining the problem, several causal factors were identified. The error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the small, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his quest for care, he came across some hurdles that eventually led to his death. Amongst one of the many issues that led to complications was the fact that the hospital was short staffed with only one RN, Nurse J., and one LVN on shift. There was also only one ED physician, Dr. T. At the time of Mr. B’s arrival, two other patients were being cared for. As Mr. B was being treated, a patient that was in respiratory distress was being admitted. Meanwhile, the two patients that had been seen earlier were awaiting discharge instructions and the ED waiting room had also become much busier. There was additional backup staff present (including a respiratory therapist) that could have been called upon for help, yet they never were. The charge nurse or nurse supervisor could have stepped in at this point to provide additional help. A lack of present nursing staff and support can lead to unfavorable patient outcomes, as is the case with Mr. B. Additionally, the staff on duty could have lacked training regarding protocols or their training could have been out of date. A1. Errors or Hazards Not only did insufficient staffing contribute to the causes of this particular event, but human error also played a significant role. When Mr. B arrived at the ED, he was hyperventilating. His leg “appeared shortened.” He had edema in his calf, ecchymosis, limited ROM, and he rated his pain at a ten out of ten. Mr. B also had a history of prostate cancer, impaired glucose tolerance, elevated cholesterol and lipids, and chronic pain. He was admitted to the ED with a plan to relocate his hip. Dr. T ordered diazepam 5.0 mg to be administered through IVP and then just five minutes later ordered 2.0 mg hydromorphone to be administered because it appeared that the diazepam was not having the intended sedating effect. Again, just five minutes later, Dr. T was still not satisfied with the level of sedation and instructed the nurse to administer another dose of each of the medications. It was not until after the final medication administration that the physician noticed that the patient had not been initially sedated because of his increased weight and because he was already regularly taking oxycodone to treat his chronic pain. Nurse J. administered the medications without questioning the orders, which in turn contributed to the causes of this incident. The list of Mr. B’s current medications was never evaluated to see if there would be any medication interactions. Concurrent use of benzodiazepines and narcotics increases the risk of respiratory depression. At this time, Mr. B ‘s BP was 110/62 with a pulse oximetry reading of 92%. The respiratory therapist on shift should have been called upon to monitor Mr. B while the nursing staff attended to other patients. Mr. B was not put on any supplemental oxygen, ECG monitoring, nor were his respirations being monitored. Hospi...

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