Root Cause Analysis Essay

Root Cause Analysis (RCA) is a process that is used to identify the causes of an error or accident. In the case of Mr. B death, a RCA is needed to determine what may have contributed to his death. A Root Cause analysis must be complete and reported to Joint Commission in the even where injury or death occurs. Sentinel event is a major adverse even that could have been prevented (Alemi, 2007). The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. The people that would likely be involve in the RCA are the ER physician, the patient nurses including the LPN, ER manager, charge nurse on duty that shift, and the Chief Nursing Officer (CNO) of the hospital. They will meet to discuss the possible cause of Mr. B’s death. The first step in RCA is to data collection. They will assemble patient’s vital signs, his history, and his complaint that the time of arrival and document notes on his since his admission to the hospital. The second step in
B, which included poor staffing, the Emergency room was packed with patients and not enough employees to properly monitor and treat them. The blood pressure alarm being silenced by the staff prior to investigating the cause for the buzzing is another mistake by the nurse. Another error by the nurse is that she failed to provide supplemental oxygen to patient prior to imitated diazepam and hydromorphone. The nurse should have known that those medications can cause major respiratory depression and should have taken the precaution necessary to prevent any complication that may have resulted from those two medications. Another error is both the physician and the nurse fell to notice that Mr. B arrived to the hospital with his left leg being shorter than the right leg, red, and swollen. The nurse should have document the condition on of the leg and do a more focus assessment on the extremities to check to