Mr B Root Cause

1744 words 7 pages
RTT1 Organizational Systems Task 2
The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care
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One pertinent error is overdosing Mr. B with hydromorphone. Mr. B was given a total dosage of 4 milligrams of hydromorphone within five minutes. Hydromorphone is a highly potent opiate that must be carefully monitored for severe respiratory depression.

B. Improvement Plan
An improvement plan, stemming from change theory, must be in place in order to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. The change theory utilized in this scenario would be the Associates in Process Improvement’s Model for Improvement. The first half of the model has three fundamental questions:
1. Aim: What are we trying to accomplish? 2. Measures: How will we know a change is an improvement?
3. Changes: What change can we make that will result in improvement?
(Lloyd, 2009)
The second half of the Model for Improvement is the testing phase developed by Walter Shewhart called the PDSA cycle, which stands for Plan, Do, Study, Act. This four-step cycle is a simple mechanism to quickly test and tweak changes made in the process. Let us apply the Model for Improvement to Mr. B’s scenario. The aim of the improvement plan is to quickly screen for deep vein thrombosis in emergency room patients. Measures include performing a D-Dimer blood test, a diagnostic test that determines the probability of a patient having deep vein thrombosis. Another measure is to implement a flowchart detailing the signs and symptoms of deep vein thrombosis.


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