Sat Task 2

3077 words 13 pages
A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) …show more content…

The IHI mentioned that “the causal statement links the cause to its effects and then back to the main event that prompted the RCA in the first place” (Huber & Ogrinc, 2010). In the given scenario, Mr. B was admitted for severe left leg and hip pain after a fall. He was given a total of four milligram of hydromorphone IVP and ten milligram of diazepam IVP within ten minutes in order to sedate him prior to reduction of his left hip. He did not have supplemental oxygen and was not connected to ECG monitor. The ER department was busy and understaffed. Nurse J and the LPN got busy with the new respiratory distress patient. They were also discharging other two patients and managing incoming patients. Mr.B’s oxygen saturation dropped from 92%, then 85% and finally 79% after high doses of diazepam and hydromorphone were given. He experienced respiratory depression because of the high doses of medications given in a short period of time. He then became hypoxic because he was not given supplemental oxygen while his oxygen saturation was dropping. As a result, Mr. B suffered severe brain damage which caused him to code and to die unexpectedly. The fifth step of RCA process is creating a list of recommended actions to prevent the event from happening again (Huber & Ogrinc, 2010). Based on Mr. B’s scenario, the following recommendations are necessary in order to prevent the reoccurrence of the sentinel event. First and


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