Wgu Org Sys2Tems Paper 2
Gina Potter
000203903
Western Governor’s University
January 31, 2016, 2016
The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will then be …show more content…
Upon analyzing the data, the RCA team looked at the causative factors, and events that led up to Mr. B’s death. The RCA team then determined that the ultimate root cause of Mr. B’s death was in fact a medication error. It was documented that Mr. B was in fact given an overdose of hydromorphone during