Getting To The Root Of The Problem

2877 words 12 pages
Organizational Systems and Quality Leadership
RTT1: Task 2 Sections A through D
A. Root Cause Analysis (RCA): A Systems Approach To Error
The RCA seeks to answer four questions:
1. What happened?
a. Patient admitted to triage with probable dislocated / fractured hip status post fall at home.
b. Vital signs: B/P 120/80, HR-88 NSR, T-98.6, RR-32, weight: 175 pounds.
c. Pain rated 10/10.
d. Assessments reveals: Patient appears to be in moderate distress, left leg appears shortened with calf edema, ecchymosis, and limited ROM.
e. Patient’s leg is stabilized and patient is admitted to emergency department.
f. Admitted by Nurse J.
g. RN assesses the patient, updates the ED MD with the assessment findings,
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B.
4. How do we keep this from happening again?
a. A presedation plan must be implemented and followed prior to sedation.
b. Presedation assessment must be completed prior to sedation and must be placed in patient’s chart.
c. All patients requiring moderate sedation will be 1:1 RN care, with respiratory therapy consult.
d. Supplemental oxygen must be used on patient’s receiving sedation if the oxygen saturation falls below 96%.
e. Level of sedation will be assessed using the following sedation scale:
e.i. S = Sleep, easy to arouse
e.ii. 1 = Awake and alert
e.iii. 2 = Slightly drowsy, easily aroused
e.iv. 3 = Frequently drowsy, arousable, drifts off to sleep during conversation
e.v. 4 = Somnolent, minimal or no response to physical stimulation
f. Medication administration for sedation must be monitored by a trained anesthesia provider.
g. Clear discharge criteria will be followed.
g.i. Patient is as alert and orient as baseline
g.ii. Presence of gag reflex
g.iii. Stable vital signs consistent with baseline for 30 minutes after last drug dose
g.iv. Oxygen saturation on room air at least 95% or at baseline for 30 minutes after last drug dose
g.v. Cardiac rhythm consistent with baseline
g.vi. BP and heart rate within 20 points of baseline or within normal limits
g.vii. Temperature not above 101E F
g.viii. Pain rating < or = to baseline
h. Due to the fact that Valium is associated with great variation in response,

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