Wgu Organizational Trends Essay

2014 Words Jan 12th, 2016 9 Pages
Organizational Leadership


A. A complete root cause analysis (RCA) that incorporates the causative factors, errors, and hazards that led to the patient’s outcome or sentinel event.

Sentinel event refers to the occurrence of serious physical illness or death or psychological injury or even those incidences whose recurrence involves risks with adverse and serious outcomes. It may result into deaths that are not anticipated or permanent loss of a major function that is not associated with patient’s natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B’s demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG monitor
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There could also be a witness required of another licensed staff member and have them cosign that all necessary equipment/patient is attached to all monitoring devices and O2 according to the sedation policy. A post sedation/procedure flowsheet could also be implemented where assessments could be documented every five minutes to include that all monitoring equipment, oxygen is checked and working. This flowsheet/assessment could then be increased to ten minutes, fifteen minutes until patient is stable according to policy requirements. These assessments would be required to be documented by licensed personnel who have been trained on the sedation policy.

1. Discussion on a change theory that can be employed to implement the process improvement plan developed in B above

A change theory to the developed action plan in B above should have 3 steps such as the three-stage model of change that is known as the unfreezing-change-refreeze model that requires prior learning to be rejected and replaced. This is known as the Lewin Change Theory.

Step one is known as unfreezing, this is the process which involves finding a method of making it possible for people to let go of an old way of doing things and being open to new ideas or ways

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