A root cause analysis (RCA) is a process used to determine why an incident or error occurred and used to develop effective solutions to prevent a reoccurrence. This process addresses three basic questions, what is the problem, why did it occur, and what can be done to prevent it (Root Cause Analysis, nd)? The root cause analysis is not designed to point fingers at individuals, its purpose is to help fix the issues or problems within systems or processes. Improvement is the goal, not to blame. RCA’s are used to ask questions and to analyze situations. RCA’s occur after a problem or issue has occurred. The multidisciplinary teams explore causes for the error. The Joint Commission requires a root cause analysis to be performed on all sentinel
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There are many safety risks or errors in regards to Mr. B.’s care and treatment in this scenario. This paper will focus on staffing, documentation, and education. Based on the scenario documentation issues begin at the point of admission point Mr. B.’s care in the given scenario. There are several things not documented that are important to patient care in this scenario. Allergies are not documented. A patient should be asked regarding allergies prior to providing any care to avoid any potential food, drug and environmental interactions. An accurate health history should be obtained at admission. There is missing documentation regarding the source and timing of Mr. B.’s injury in regards to the swelling and bruising in his calf. Documentation does not indicate if the swelling and bruising was present before or after his fall, not sure if the staff asked the patient or his son who is present about this issue. Treatment and procedures might have been modified if the problems were present before the fall happened. Swelling and bruising in the calf can indicate a blood clot which could have been dislodge with manipulation of his leg, if dislodge from his calf could have traveled to his heart or lung, a clot that travels to the heart can cause a cardiac event and a clot the travels to the lungs could cause breathing difficulties, which after the conscious sedation procedure …show more content…
Weight was addressed but height was not, each one should be addressed and documented at time of patient admission before any treatment begins, unless patient is in an emergent situation. Some medication given are based on weight and height, accurate height and weight need to be obtained as soon as possible. Accurate documentation will ensure appropriate doses of medication are given, if dosed based on weight. The amount of medication given to him during the sedation process might have been too much based on his size, not having a height documented. The physician ordered both narcotic (Dilaudid) and sedative (Valium) medication, he consequently ordered additional doses (was given Valium 5mg and additional 5mg and Dilaudid 2mg and additional 2mg) of the medication before allowing enough time for medication to take full effect. Administering additional doses and combining the medication might have caused Mr. B. to become over sedated. Over sedation can result in decreased oxygen level and lower blood pressures (58/30 and 79%) as in the scenario. The potential for life threatening conditions such as the ventricular fibrillation and respiratory distress or arrest can result from over sedation, as
There are many safety risks or errors in regards to Mr. B.’s care and treatment in this scenario. This paper will focus on staffing, documentation, and education. Based on the scenario documentation issues begin at the point of admission point Mr. B.’s care in the given scenario. There are several things not documented that are important to patient care in this scenario. Allergies are not documented. A patient should be asked regarding allergies prior to providing any care to avoid any potential food, drug and environmental interactions. An accurate health history should be obtained at admission. There is missing documentation regarding the source and timing of Mr. B.’s injury in regards to the swelling and bruising in his calf. Documentation does not indicate if the swelling and bruising was present before or after his fall, not sure if the staff asked the patient or his son who is present about this issue. Treatment and procedures might have been modified if the problems were present before the fall happened. Swelling and bruising in the calf can indicate a blood clot which could have been dislodge with manipulation of his leg, if dislodge from his calf could have traveled to his heart or lung, a clot that travels to the heart can cause a cardiac event and a clot the travels to the lungs could cause breathing difficulties, which after the conscious sedation procedure …show more content…
Weight was addressed but height was not, each one should be addressed and documented at time of patient admission before any treatment begins, unless patient is in an emergent situation. Some medication given are based on weight and height, accurate height and weight need to be obtained as soon as possible. Accurate documentation will ensure appropriate doses of medication are given, if dosed based on weight. The amount of medication given to him during the sedation process might have been too much based on his size, not having a height documented. The physician ordered both narcotic (Dilaudid) and sedative (Valium) medication, he consequently ordered additional doses (was given Valium 5mg and additional 5mg and Dilaudid 2mg and additional 2mg) of the medication before allowing enough time for medication to take full effect. Administering additional doses and combining the medication might have caused Mr. B. to become over sedated. Over sedation can result in decreased oxygen level and lower blood pressures (58/30 and 79%) as in the scenario. The potential for life threatening conditions such as the ventricular fibrillation and respiratory distress or arrest can result from over sedation, as