A. Root Cause Analysis Root cause analysis (RCA) is a system-oriented and team-oriented approach to understanding errors and accidents to prevent reoccurrence. An RCA team works together to understand what happened, why it happened, how to prevent future adverse events, how system changes will improve safety. Commonly, used in healthcare, an RCA is only useful if results in a specific action that improves the safety of the system. Ideally, by using RCA, failures will be converted into learning opportunities for improvement (Williams, D. & Butts-Dion, S., 2016) A1. RCA Steps The first step in the RCA is to form a team. The team should be comprised of interprofessional individuals with a fundamental knowledge of the issues and processes involved …show more content…
B death was brain death from cardiac and respiratory arrest. The Code team worked on reviving Mr. B for thirty minutes after he suffered from unresponsiveness, pulselessness, hypotension, hypoventilation and ventral fibrillation. Mr. B had severe brain damage from lack of oxygen and blood to his brain. A week after the event, Mr. B’s family removed him from life support ultimately ending his life. Many contributing factors lead to Mr. B’s death. The first causative factor is Mr. B’s characteristics. He has recent lab work showed elevated cholesterol and lipids which put him at risk for cardiac issues. He takes oxycodone regularly for his chronic back pain which makes him harder to sedate. After the closed reduction procedure, Mr. B was so sedated that he did not display distress from his dropping oxygen level. The second causative factor is task factors (Ogrinc, G. & Huber, S., 2010). The hospital had a conscious sedation policy in which Mr. B should have been on continuous blood pressure, electrocardiogram (ECG) and pulse oximeter monitoring throughout the procedure and until he met discharge criteria. However, this policy was not followed in Mr. B’s case. All practitioners administrating conscious sedation must pass training modules. Nurse J had completed the training modules but the LPN was the nurse checking on Mr. B. The LPN did not notify Nurse J of low oxygen
At noon, while staff were having difficulty attempting to draw blood, Lewis became unresponsive. Helen called for help and Dr. Murray arrived to the room (Monk, 2002). A code was called and the on-call physician, Dr. Adamson, arrived and subsequently attempted to resuscitate Lewis for an hour before calling a time of death at 1:23pm (Kumar, 2008; Monk, 2002). An autopsy later revealed that Lewis Blackman died from internal bleeding caused by a perforated ulcer with close to three liters of blood and digestive fluid
2) “It’s difficult to determine who provides anesthesia care in the studies and the number of cases that actually involved a physician anesthesiologist (p. 11)” the ASA is claiming that the data collected and used in this review, are difficult to determine who did what and when. In other words it is unclear as to who was performing and providing care in these studies and very well could be, the care provided by an anesthesiologist. They say also that the data provided and used by the study has limiting factors to determine whether an anesthesiologist was available as needed, for rescue or advice by a patient being treated by a nurse anesthetist if they were to experience complications under the
The patient presented with common signs of compartmental syndrome. The interventions suggested to the staff at the hospital were not fully completed. The interventions given during the case presentation consisted of assessing the six Ps, swelling, and vital signs. I took the vital signs of the patient and the nurse recorded them in their system. The patient’s blood pressure was not within normal limits, so the blood pressure completed manually. The manual blood pressure was still elevated. An increase in blood pressure can indicate pain, swelling, and impaired blood flow to the extremities. When I was with the nurse, she sent the patient for an x-ray. Furthermore, the nurse should have then assessed what the patient has been doing and done education with the patient to elevate the leg above his heart. Many people do not know the scientific rationale and positioning of elevating the extremity above the heart. The nurse should have also assessed the patients expectation of pain relief, since his current medication (Ibuprofen) was not working to his expectations. This is when we left the floor; therefore, I was not able to discuss the patient care with the nurse. The nurse simply asked the patient about some of the six Ps of compartmental syndrome and did not complete the assess...
A death that occurs in a patient due to preventable complications is called failure to rescue (Mackintosh). A patient in an
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.
As a result, she breached the standard 6 which states that “registered nurse should provide a safe, appropriate and responsive quality nursing practice” (NMBA, 2016). In line with this standard, nurses should use applicable procedures to identify and act efficiently to potential and actual risk such as unexpected changing patient’s condition (NMBA, 2016). Through early identification and response by the nurse, this will ensure that the patient’s condition is recognised and appropriate action is provided and escalated (Australian Commission on Safety and Quality in Health Care, 2011). Moreover, the nurse did not immediately escalate the patient’s deteriorating condition to the members of the health care team. Therefore, she also disregards the standard 4.3 stating that nurses should have work with the interdisciplinary health care team and to collaborate, communicate and discuss the patient’s status (NMBA,2016). The purpose of collaborating and communicating with the team is to provide a comprehensive plan of care for the patient and to facilitate early treatments needed by the patient (Cropley,
That is the rising number of negligent acts committed by medical professionals. Failure to follow standard of practice is the leading root cause of the troubles involving malpractice. Failure to assess and monitor the patient, failure to communicate, medication errors, negligent delegation or supervision and failure to obtain informed consent from patients are the top failures leading to malpractice. The American Nurses Association provides scopes and standards that if followed could prevent many of the negligent acts. Duty, Breach of Duty, Foreseeability, Causation, Injury, Damages must be proven for a nurse to be held
In the case of Mr. B’s, an investigation into the events surrounding to and leading up to his untimely death would be required. Once the problem has been identified and described, data of events are collected and formatted into a timeline. From the events, any problems in the care of the patient which may have contributed to the end result are identified and determined whether they are causative. In appendix A, the timeline of the event is outlined.
The term “failure to rescue” refers to a clinical scenario where hospital doctors, nurses, or caregivers fail to recognize symptoms. Responders do not respond adequately to clinical signs that would prevent harm (Morse, 2008, p.2). Dr. Jeffery H. Silber, Director of the Center for Health Outcomes and Policy Research, first coined the term “failure to rescue” in the 1990’s. He characterized the matrix of institutional and individual errors that contribute to patient deaths as “failure to rescue” (Aleccia, 2008). Since 1990, it has been well documented patients usually exhibit signs and symptoms of impending cardiac or respiratory arrest 6-8 hours before an arrest (Schein, Hazday, Pena, Ruben, & Spring, 1990). Buist, Bernard, Nguyen, Moore, and Anderson’s (2004) research reported similar findings. They found patients had documented clinically abnormal signs and symptom prior to arrest (Buist, et al., 2004). When certain abnormal signs and symptoms are identified early, critical bedside consultat...
Kemp, J. S. et al. Unintentional Suffocation by Rebreathing: A Death Scene and Physiologic Investigation of a Possible Cause of Sudden Infant Death. Journal of Pediatrics. 1993;122:874-880.
In the scenario provided, there were several key factors that could have resulted in a poor quality outcome for the patient. There were a number of tasks assigned to the Licensed Vocational Nurse (LVN), which required special training or competency. It was difficult to validate that the LVN had been deemed competent to perform the more specialized skills with the information available. Clarifying the LVN’s skill set and having full understanding of her training would have been critical for the RN in charge. Further, the LVN was simply not delivering the care that had been assigned. The RN needs to critically evaluate the situation. The LVN may have felt intimidated, lacked the skill, failed to understand the assignment, or any other variety of reasons. The point is the patient was not receiving the care needed and an intervention was required. “Delegation is both an art and a science. It includes cognitive, affective, and intuitive dimensions,” states Marjorie Barter (2002). All RN’s, regardless of assignment, should remember that “leaders do more than delegate, dictate, and direct. Leaders help others achieve their highest potential,” (American Nurses Association). The RN would have been remiss in not pursuing an answer to why the LVN appeared to be avoiding ce...
This may happen due to the nurse thinking it is the patients fault, and therefore thinking they do not deserve the same quality of care as the next person. This is not fair to the patient, as one never knows what the underlying cause is, that has led to the situation. It is really important to form a good patient nurse relationship, and to get all the facts, in order to assure this does not happen.
Several ethical principles that are incorporated in the nursing care of patients on a daily basis are nonmalificence, autonomy, beneficence, justice, fidelity and paternalism. Nurses should strive to comply to as many of the principles as possible. In this case there are principles which support and conflict with the wishes of the patient. The first principle that supports the wish of the patient is autonomy. Autonomy means that competent patients have the right to make decisions for themselves and the delivery of the healthcare that they receive. Another factor that would support the patient’s wish to not be resuscitated is nonmalificence. Non maleficence means that nurses should not cause harm or injury to their patients. In this case the likelihood of injury after resuscitation was greater than if the patient were allowed to expire. A principle that could have negatively affected the outcome of the provision of ethical care was paternalism. Paternalism is when a healthcare provider feels that they know what is best for a patient, regardless of the patient’s desire for their own care. I demonstrated the principle of paternalism because I thought that I knew what was best for the patient without first consulting with the patient or family. This situation might have had some very negative consequences had the patient not have been competent. Practicing a paternalistic mindset might have caused a practitioner in the same instance to force their ideas about not resuscitating the loved one onto the family. This could have caused a sense of remorse and loss of control of care amongst the
Current definitions of life and death have been categorized into two different cases: neurological and cardiorespiratory. Each category has a definite list of qualifications in order for death to be determined. Just the same, each category has contradictions and odd cases in which cardiorespiratory or neurological function are restored. 4 These contradictions leave room for opposition to the new definition of death. Many people and religious groups are not satisfied with the two categories of death. Scholars urge all to consider life as a social construct. We may not be able to determine death positively, but we can consider a patient’s quality of life, level of personhood, interaction with their external environment, and ability to maintain vital signs organically. These considerations may be a step toward the most modern definitions of life and death.
In Patient A’s case, he was lucky enough (in the most morbid way possible) to...