Running Head: ORGANIZATIONAL SYSTEMS
ORGANIZATIONAL SYSTEMS 2
This paper is the analysis of the avoidable sentinel event of Mr. B, a sixty-seven year old patient who was admitted to the emergency room with left leg and hip pain following a fall. A root cause analysis will help identify key elements which led to the unfortunate event. A plan of action to develop a change theory will help formulate an improvement plan to prevent future occurences like that of Mr. B. A failure mode and effects analysis will be discussed to test the projected plan for improvement. Finally, the roles that the nurses will play in this plan to improve this quality of care will be discussed. Root Cause Analysis
The problem statement is that Mr. B was overmedicated , and went into respiratory arrest which lead to brain death and his eventual death. The key people involved in this event were the Emergency Department Doctor, Dr. T., the ER nurse J., and the LPN. A thorough assessment was neglected to have been performed in triage. They failed to ask Mr. B. if he had taken any medications prior to this arrival, and they did not question his reactions to medications, especially to his home pain medication Oxycodone. After the initial administration of the I.V. diazepam with the hydromorphone, the ER doctor should have waited an additional 10 to 15 minutes before administrating another dose since Mr. B. has built up a tolerance to opiod medications from taking Oxycodone for his chronic back pain. The the nurse and the ER doctor both failed to take into consideration the half life and the duration of the drug, which can take up to three hours. When Mr. B's oxygen saturation went down to 92 the nurse failed to monitor his...
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