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.
Chief Nursing Officer
Emergency Department Medical Director
Emergency Department Unit Manager
Nursing Shift Supervisor
LPN on duty
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 several days, the family removed the patient from the ventilator and the patient expired.
This Adverse Event was the result of a PROCEDURAL COMPLICATION |JCAHO Inquiry |Processes/Procedures evaluation re: |Results | |Question |effectiveness | | |2 |Physical Assessment Process | | | | | | |5 |Care Planning Process |Plan of care for the administration of “Conscious Sedation” not | | | |followed based on policy and procedure. | |7 |Staffing Levels |Inadequate staffing in the ED. (1) RN. Supervisor not called for | | | |additional staffing | | | | | |8 |Orientation and Training of Staff |Administration of Conscious Sedation- only (1) RN in the ED educated | | | |regarding the procedure for administration of conscious sedation. | | | |Only (1) Critical care trained RN in the ED. | |...
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