RTT2 Organizational Systems Essay

3997 Words Mar 26th, 2015 16 Pages
RTT Task Two: Case Study
Western Governors University

Sentinel Event Case Study
Human interaction between individuals and systems does not occur in a vacuum, rather it occurs in a dynamic and multidimensional setting. From a structural and procedural system performance perspective, the nursing care environment “is perfectly designed to get the results it gets” (LLoyd, Murray, & Provost, 2015). When mistakes happen in healthcare, all Joint Commission accredited healthcare organizations are obligated to analyze the care environment to assess for opportunities to improve the structural and procedural elements that lead to care failures, as in the fictitious sentinel event case of Mr. B who presented to the emergency department for a
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Mr. B’s vital signs are noted as stable at 16:35, an unspecified amount of time later the LPN responds to an alarm indicating Mr. B’s low SpO2 of 85% and intervenes by resetting the alarm and initiating another blood pressure reading without noting the results or addressing the SpO2 value. At 16:43, the patient’s son alerts Nurse J to another alarm and the RN notes vital signs of blood pressure 58/30, SpO2 79%, respirations undetected and no pulse palpable. A code is called, Mr. B is first noted to be in ventricular fibrillation, chest compressions are then initiated, and the subsequent ACLS interventions result in Mr. B being ventilator dependent with fixed/dilated pupils, nonreactive to noxious stimuli, and blood pressure 110/70 with sinus rhythm and regular pulse. He is transferred to a higher level of care and passes away 7 days later.
The second step on which the RCA team will embark is a detailed second flow chart of what should have happened. “By placing the two flowcharts side by side, the team can clearly see the differences between the ideal process and the actual process that led to the adverse event. This can help further pinpoint contributing factors later in the process” (Huber & Ogrinc, 2015, p. 9). In the case of Mr. B, several hazards and errors would be uncovered during this part of the RCA. As a select example, the comparison of the flow charts would reveal that the manual reduction of Mr. B’s hip using conscious sedation had known

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