Root Cause Analysis In Nursing

1695 Words 7 Pages
The Policy problem
A. Root Cause Analysis
The scenario consists of a 67 year-old male arriving at the emergency room (ER) due to a fall. The patient exhibits increased respirations, edema in the calf, possible hip fracture, and pain ten of ten. Past history of elevated cholesterol and lipids, chronic back pain for which he takes medications of atorvastatin and oxycodone. Patient receives diazepam and hydromorphone, but is not monitored appropriately. Respiratory depression occurs along with ventricular fibrillation. CPR and defibrillation is completed,and patient is placed on life support. Next, determined to be brain dead, removed from life support, and expires. A root cause analysis (RCA)
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The LPN silenced the alarm, failed to notice the B/P was declining, and did not report it which allowed the patient to decline further. Lack of knowledge by staff to investigate whether a deep vein thrombosis had occurred and then not reacting to it might have caused more respiratory distress.
Nonchalance towards alarms or becoming complacent. The LPN should have investigated why the alarms were sounding and reacted to it instead of letting the patient decline further.
Failure to assess for DVT was another contributory factor. Signs and symptoms of a DVT were missed such as the calf edema, increased respirations, pain “ never felt like before”, elevated cholesterol/lipids, and possible hip fracture. The DVT could have broken loose and turned into a pulmonary embolus and caused more respiratory distress.
B. Improvement Plan
The RCA is completed and studied and now it is time to create a plan to prevent an occurrence like this from happening again. The plan will be implemented by process changes and behavior changes. The process would be changed by way of a new procedure. Behavior would be changed using the change theory. In this scenario, development of a new procedure from input from the
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First step is called unfreezing. During this step groundwork is laid to give reasons why the new policy is required. An imbalance between old and new procedure is imparted. The imbalance should shift in favor of the new procedure (Sauls, Change, 2014). Valid reasons for change should be supplied. There will be resistance to change but supplying valid reasons will help overcome this (Williams, 2009). The new procedure for conscious sedation that will be adopted to prevent recurrence of overmedicating that led to the patient’s death. Using the new procedure will make safety in the use of conscious sedation a priority. The new procedure will be talked about in weekly meetings, on the floor, through literature, and through e-mail

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