Root Cause Analysis In Nursing

1326 Words3 Pages

A root cause analysis is a mechanism used to determine if procedures prompt sentinel occasions. A sentinel occasion is characterized by Cherry and Jacob as "a startling event that can cause genuine physical or psychologic damage or the danger thereof." (Cherry and Jacob, 2011, p. 444) The goal of a root cause analysis is to distinguish the components which brought on the sentinel occasion and to recognize imperfections in the framework which can be adjusted with a specific end goal to keep a rehash of the occasion later on. A root cause analysis is not used to accuse people, and is not relevant when the occasion is deliberate, or brought on by carelessness or a criminal intent. Root cause analysis concentrates on disappointments in the framework …show more content…

As the quantity of patients expanded, it ought to have been obvious that one registered Nurse and one Licensed Practical Nurse were insufficient to look after the patients. The emergency department ought to be viewed as a high priority location, and should have staffed with more Registered Nurses; Licensed Practical Nurse essentially do not have the training and abilities to assess patients or delegate the workload. Dangerous actions such as moderate sedation on a patient with no supplemental oxygen or EKG observing. The patient seems to have been overmedicated, with insufficient time between medications to decide his actual level of …show more content…

We will do this (the second step) for two months, while getting the patient 's, the relatives of the patients to rate the staff efforts, their stay, and the accessibility of the medical staff before they are released. We will likewise have the nursing staff to fill us in as to whether that nursing model is working, what requirements to change, and in the event that they could successfully take care their patients. I would need the studies rounded out on the days that we are attempting the new staffing model, and in addition the days when we are most certainly not. I will then finish step three, which is study and dissect the outcomes from the reviews. Step four is act, where in view of what is found out from my test, I will enhance the change by figuring out what updates should be made, and if need test it again with the new changes

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933 Words | 2 Pages
The NHS change model uses a systematic approach and structure to positively engage staff towards implementing change and a detailed approach to plan the change. The eight dimensions of the model, guide the cycle of change by a succession of small steps, allowing for regular reassessment. The NHS change model encourages the use of reassessment to ensure the quality improvement remains focused and maintains staff engagement with the change.
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Long Term Acute Care Hospital
649 Words | 2 Pages
Examples of patients with complex acute care needs are those with multiple comorbidities who need mechanical ventilator weaning, administration of intravenous antibiotics, and those with complex wound care (Munoz-Price, 2009, p. 438). According to Landon Horton, CNO of Select Specialty Hospital in Fort Smith, Arkansas, “The services provided by LTACH facilities allow the patients to get home who would not otherwise, have a higher level of functioning at discharge, and increase their quality of life” (personal communication, March 7, 2014). The role of the Chief Nursing Officer is a complex position. Educational preparation for the CNO role ranges from a Master’s in Nursing to a degree outside of the profession such as an MBA or a degree in a related area of study (Kerfoot, 2012, p. 38-39). In L. Horton’s role as the CNO for Select Specialty Hospital, the duties required by him are multifaceted.
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Root Cause Paper
861 Words | 2 Pages
Furthermore, there should be enough trust between the nurses and physicians where they can easily put aside their egos and ask for a second opinion when they have any doubts concerning a patient's safety. This was clearly exemplified when the nursing staff attending to Lewis Blackman failed to contact the physician when various side effects arose; instead they tailored the signs to fit the expected side effects. Even after Blackman’s health was deteriorating, the nurses remained in their “tribes” and never once broke out of it to ask for help. The entire hospital was built on strong culture of remaining in their tribes instead of having goals oriented towards patients care and safety.
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Improving Long-Term Care Admissions Policy: A Voice of Change
1030 Words | 3 Pages
Thirty minutes before evening shift change and you receive the call. A new admission is in route to your facility. The patient is reported to be of high acuity, requires intravenous antibiotics, and has a diagnosis of chronic pain. In some health care settings this would be considered a typical new patient admission. However, for rural long-term care facilities there is potential for considerable complications. In a setting where registered nurses are only required to be in the facility eight hours within a twenty-four hour time frame, significant complications can arise during admissions that require certain specialty care specific to the RN. Ineffective discharge planning between any health care settings can be detrimental to patient care.
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Nursing And Unsatisfactory Professional Conduct In Nursing
1253 Words | 3 Pages
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Capacity and Consent: Paramedic Reflection
957 Words | 2 Pages
My colleague and I received an emergency call to reports of a female on the ground. Once on scene an intoxicated male stated that his wife is under investigation for “passing out episodes”. She was lying supine on the kitchen floor and did not respond to A.V.P.U. I measured and inserted a nasopharyngeal airway which was initially accepted by my patient. She then regained consciousness and stated, “Oh it’s happened again has it?” I removed the airway and asked my colleague to complete base line observations and ECG which were all within the normal range. During history taking my patient stated that she did not wish to travel to hospital. However each time my patient stood up she collapsed and we would have to intervene to protect her safety and dignity, whilst also trying to ascertain what was going on. During the unresponsive episodes we returned the patient to the stretcher where she spontaneously recovered and refused hospital treatment. I completed my patient report form to reflect the patient's decision and highlighted my concerns. The patient’s intoxicated husband then carried his wife back into the house.
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Nursing Codes In Nursing Practice
887 Words | 2 Pages
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Components of Leadership and Management Roles for Nursing
2020 Words | 5 Pages
..., Watson, and Westley Planned Change Model consists of seven phases which the change is planned, implemented, and the evaluated (Yoder-Wise, 2011). The outcome of this issue is an ongoing process; the need has been submitted to the nurse practice council which has submitted the issue to the hospital policy board for implementation into policy (T. personal communication, April 2, 2014).
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Root Cause Analysis
1355 Words | 3 Pages
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
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aged care
1625 Words | 4 Pages
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Role Development Concepts & Issues
723 Words | 2 Pages
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Staffing In Nursing Essay
885 Words | 2 Pages
Thousands of nurses throughout the nation are exhausted and overwhelmed due to their heavy workload. The administrators do not staff the units properly; therefore, they give each nurse more patients to care for to compensate for the lack of staff. There are several reasons to why
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Essay On Patient Utilitarianism
664 Words | 2 Pages
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1036 Words | 3 Pages
Although students were not allowed in the recovery unit, I was able to talk to one of the recovery nurses. I learned that a nurse’s duty of care includes monitoring the patient’s vital signs and level of consciousness, and maintaining airway patency. Assessing pain and the effectiveness of pain management is also necessary. Once patients are transferred to the surgical ward, the goal is to assist in the recovery process, as well as providing referral details and education on care required when the patient returns home (Hamlin, 2010).
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Inadequate Nursing Essay
1812 Words | 4 Pages
Especially the patient. When cutting back on staff nurses it is imperative that the consequences are fully understood. In the end, a patient’s life is on the line. As discussed, a nurse’s role goes beyond the medical aspect, developing a relationship with the patient is vital when delivering care. A nurse-patient relationship cannot be provided when there are a bulk workload and long hours with no break period. Having a nurse staff with an adequate number of nurses is imperative to guarantees that all patients needs are met. To ensure that there are minimal errors to no errors made when delivering care, a nursing staff must have a sufficient number of nurses. Additionally, to make sure a hospital's fines are limited pertaining to patient care, an adequate number of nurses. Nurses are a key component in healthcare, however, their duties as nurses cannot be
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Root Cause Analysis In Nursing

NHS Change Model Essay

Long Term Acute Care Hospital

Root Cause Paper

Improving Long-Term Care Admissions Policy: A Voice of Change

Nursing And Unsatisfactory Professional Conduct In Nursing

Capacity and Consent: Paramedic Reflection

Nursing Codes In Nursing Practice

Components of Leadership and Management Roles for Nursing