Root Cause Analysis of a Sentinel Event

2524 words 11 pages
Diane Swintek
Western Governors University

Root Cause Analysis of a Sentinel Event
A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the
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The moderate sedation module contains a section on dosing ranges/guidelines. Mr. B received, within a fifteen minute period, Valium 10mg intravenously and Dilaudid 4mg intravenously. A Valium dosing recommendation for sedation in an intensive care unit (ICU) is 0.03mg/kg up to 0.1mg/kg at an interval range of thirty minutes to six hours. For Mr. B this would have been a dose range of 3.12mg, as the low, up to 10.4mg for an upper limit. Mr. B received 10mg of Valium in ten minutes with a full dose of an opioid analgesic. Both drugs used for this procedure are known to cause respiratory depression. This combination for moderate sedation was not the best choice. The adverse event demonstrated a lack of knowledge regarding acceptable dosing range and interval.
Consideration must be given to the staff mix of the ED that day. The emergency department has six treatment rooms and had three healthcare providers and one support staff present. Nursing personnel included an RN with critical care experience and an LPN. The emergency department is recognized as a critical care environment and not endorsed as a primary work place for a licensed practical nurse by the American Association of Critical Care Nurses (AACN). Critical care areas require advanced education to enable the nurse to critically think about the care priorities of the assigned patients. The presence of other patients requiring care, including an eight-month old


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