Wgu Rtt1 Task2 Essay

2880 Words Sep 11th, 2014 12 Pages
RTT1 Task 2 Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them.
A. Root Cause Analysis
“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A
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Nurse J. administered the medications without questioning the orders, which in turn contributed to the causes of this incident.
The list of Mr. B’s current medications was never evaluated to see if there would be any medication interactions. Concurrent use of benzodiazepines and narcotics increases the risk of respiratory depression. At this time, Mr. B ‘s BP was 110/62 with a pulse oximetry reading of 92%. The respiratory therapist on shift should have been called upon to monitor Mr. B while the nursing staff attended to other patients. Mr. B was not put on any supplemental oxygen, ECG monitoring, nor were his respirations being monitored. Hospital policy at this facility mandates that patients receiving moderate sedation/analgesia have continuous BP, ECG, and pulse ox monitoring. Neither Nurse J (who had been trained in this) nor the physician followed protocol by implementing these precautionary measures that could have possibly prevented Mr. B’s fateful outcome. He did have a blood pressure and pulse oximeter monitoring him, but when the alarm sounded and showed a “low O2 saturation (85%)” the machine was simply reset by the LPN. The LPN could have required more training in assessing blood pressure monitor readings as well as appropriate interventions regarding the

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