Quality Improvemeny Nursing
Competency 724.3.4: Quality Improvement
Lillian L. Klitsch
Western Governors University
Root Cause Analysis:
An event occurred on a Thursday at 3:30pm in the Emergency Department of a sixty-bed rural hospital.
A report was completed on February 2nd, 2011
The Root Cause Analysis Team will brief Management of the facility on February 10th,
2011 regarding the event.
Team Members:
Leader Chief Nursing Officer
Recorder Administrative Secretary
Member Quality/Risk Manager
Member Emergency Department Medical Director
Member Emergency Department Unit Manager
Member Nursing Shift Supervisor
Member Nurse J
Member LPN on duty
Member Dr. T
Description of Event:
A patient presented to the Emergency Department with the complaints of hip and leg pain. The patient rated the pain 10/10 on the standard pain scale. His (L) leg appeared shortened with swelling, ecchymosis, and limited range of motion. The leg was stabilized and then he was further evaluated and discharged to a room in the nursing department. The patient was also noted to have a history of impaired glucose tolerance and prostate cancer. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient was placed in a room and prepared for a procedure. The physician evaluated the patient and proceeded to order Valium, when unsuccessful hydromorphone was ordered. The patient had not achieved appropriate sedation for the procedure and additional medication was ordered. The patient was not placed on a cardiac monitor and a baseline oxygen level was not obtained prior to the administration of sedatives. The patient was receiving “Conscious sedation” in order for the physician to perform a manipulative procedure. The patient eventually had a decrease in oxygen saturation and became hypotensive- an arrest occurred. The patient was resuscitated and then transferred to a tertiary center. The patient was found to have brain damage and after
Lillian L. Klitsch
Western Governors University
Root Cause Analysis:
An event occurred on a Thursday at 3:30pm in the Emergency Department of a sixty-bed rural hospital.
A report was completed on February 2nd, 2011
The Root Cause Analysis Team will brief Management of the facility on February 10th,
2011 regarding the event.
Team Members:
Leader Chief Nursing Officer
Recorder Administrative Secretary
Member Quality/Risk Manager
Member Emergency Department Medical Director
Member Emergency Department Unit Manager
Member Nursing Shift Supervisor
Member Nurse J
Member LPN on duty
Member Dr. T
Description of Event:
A patient presented to the Emergency Department with the complaints of hip and leg pain. The patient rated the pain 10/10 on the standard pain scale. His (L) leg appeared shortened with swelling, ecchymosis, and limited range of motion. The leg was stabilized and then he was further evaluated and discharged to a room in the nursing department. The patient was also noted to have a history of impaired glucose tolerance and prostate cancer. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient was placed in a room and prepared for a procedure. The physician evaluated the patient and proceeded to order Valium, when unsuccessful hydromorphone was ordered. The patient had not achieved appropriate sedation for the procedure and additional medication was ordered. The patient was not placed on a cardiac monitor and a baseline oxygen level was not obtained prior to the administration of sedatives. The patient was receiving “Conscious sedation” in order for the physician to perform a manipulative procedure. The patient eventually had a decrease in oxygen saturation and became hypotensive- an arrest occurred. The patient was resuscitated and then transferred to a tertiary center. The patient was found to have brain damage and after
References: Goodman, S.L. (1996). Design for Manufacturability at Midwest Industries, Harvard Business School, February 2, 1996, Lecture McDermott, Robin E. (1996). The Basics of FMEA, Productivity. Pennsylvania Patient Safety Authority, (2010).Retrieved from http://patient safety authority.org Wachter R.M. (2007). Understanding Patient Safety New York, NY: McGraw- Hill Professional