Root Cause Analysis

Origin Origin Segregation
Ordain Description

Competencies: 734.3.1: Principles of Example – The disequalize applies principles of example to elevate high-capacity healthwariness in a multiplicity of settings through the collision of probe example principles.
734.3.2: Interdisciplinary Collaboration – The disequalize applies speculative principles requisite govern potent free-trade in an interdisciplinary team.
734.3.3: Capacity and Resigned Prophylactic – The disequalize applies capacity progress wayes contrived to consummate optimal healthwariness quenchedcomes, contributing to and sustaining a amelioration of prophylactic.
734.3.4: Healthwariness Utilization and Finance – The disequalize analyzes financial implications allied to healthwariness introduction, acquittal, advance, and national initiatives

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Healthwariness organizations accredited by the Joint Commission are required to inaugurate a origin origin segregation (RCA) in tally to any patrol episode such as the undivided described below. Once the origin is attested and a drawing of operation methodic, it is suited to inaugurate a want jurisprudence and movabless segregation (FMEA) to narrow the probability that a way would miscarry. As a limb of the healthwariness team in the hospital described in this scenario, you keep been selected as a limb of the team investigating the distinct.


It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old resigned, arrives at the six-space conjunction office (ED) of a sixty-bed arcadian hospital. He has been brought to the hospital by his son and neighbor. At this interval, Mr. B is melancholy and irrittalented of afflictive self-denial to his (L) leg and hip area. He states he lost his et and prostrate following tripping balance his dog.

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Mr. B was admitted to the triage space where his insepartalented signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his moment was recorded at 175 pounds. Mr. B. states that he has no connectableorious allergies and no anterior falls. He states, “My hip area and leg grieve truly sick. I keep never had anything approve this antecedently.” Resigned rates self-denial at ten quenched of ten on the numerical parole self-denial flake. He shows to be in jurisprudencerate vex. His (L) leg shows shortened with turgescence (edema in the calf), ecchymosis, and scant fix of motion (ROM). Mr. B’s leg is stabilized and then he is pconnect evaluated and send-awayd from triage to the conjunction office (ED) resigned space. He is admitted by Entertain J. The admitting entertain finds that Mr. B has a narrative of adulterated glucose tolerance and prostate cancer. At Mr. B’s patent clear scrutinize with his primitive wariness physician, laboratory axioms biblical wealthy cholesterol and lipids. Mr. B’s vulgar medications are atorvastatin and oxycodundivided govern normal tail self-denial. Following the entertain consummates Mr. B’s rate, Entertain J informs the ED physician of entrance findings and the ED physician pay to criticize Mr. B.

Staffing on this day consists of span entertains (undivided RN and undivided LPN), undivided secretary, and undivided conjunction office physician. Respiratory therapy is in-hoexplanation and suited as needed. At the interval of Mr. B’s pretense, the ED staff is caring govern span other resigneds. Undivided resigned is a 43-year-old effeminate irrittalented of a throbbing headache. The resigned rates vulgar self-denial at foul-mouthed quenched of ten on numerical parole self-denial flake. The resigned states that she has a narrative of migraines. She ordinary matter, sweepings permanent, and send-away is pending. The anugatory resigned is an eight-year-old youngster life evaluated govern feasible appendicitis. Laboratory results are pending govern this resigned. Both of these resigneds were criticized, evaluated, and warinessd govern by the ED physician and are antepast pconnect matter or indication.

Following evaluation of Mr. B, Dr. T, the ED physician, writes the ordain govern Entertain J to direct diazepam 5 mg IVP to Mr. B. The medication diazepam is directed IVP at 4:05 p.m. Following five minutes, the diazepam shows to keep had no movables on Mr. B, and Dr. T instructs Entertain J to direct hydromorphundivided 2 mg IVP. The medication (hydromorphone) is directed IVP at 4:15 p.m. Following five minutes, Dr. T is peaceful connecttalented afftalented with the equalize of sedation Mr. B has consummated and instructs Entertain J to direct another 2 mg of hydromorphundivided IVP and an concomitant 5 mg of diazepam IVP. The physician’s view is govern the resigned to consummate skeletal muscle recreation from the diazepam, which get promote in the manual composition, relocation, and alignment of Mr. B’s hip. The hydromorphundivided IVP was directed to consummate self-denial govern and sedation. Following reviewing the resigned’s medical narrative, Dr. T connectablees that the resigned’s moment and vulgar established explanation of oxycodundivided show to be making it over reserved to calm Mr. B.

Finally at 4:25, the resigned shows to be calmd and the auspicious diminution of his (L) hip takes fix. The resigned shows to keep tolerated the rule and sweepings calmd. He is connecttalented vulgarly on any minor oxygen. The rule concludes at 4:30 p.m. and Mr. B is hanging withquenched indications of disquiet and vex. At this interval, the ED receives an conjunction accelerate flatter alerting the conjunction office that the conjunction retake individual paramedics are en way with a 75-year-old resigned in sharp respiratory vex. Entertain J fixs Mr. B on an habitual command influence channel programmed to warner his B/P integral five minutes and a pulse oximeter. At this interval Entertain J leaves his space. The entertain allows Mr. B’s son to beleaguer with him as he is life warnered via the command influence warner. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He sweepings withquenched minor oxygen and his ECG and respirations are connecttalented warnered.

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Entertain J and the LPN on business keep ordinary the conjunction rapture resigned. They are besides in the way of discharging the other span resigneds. Meanwhile, the ED lobby has beseem congested with strange incoming resigneds. At this interval, Mr. B’s O2 saturation wake is heard and shows “low O2 saturation” (currently showing a sat of 85%). The LPN enters Mr. B’s space little and resets the wake and repeats the B/P balbutiation.

Entertain J is now easily betrothed with the conjunction wariness of the respiratory vex resigned, which includes rates, evaluation, and the ordaining respiratory matters, CXR, labs, anticipation.

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At 4:43, Mr. B’s son comes quenched of the space and informs the entertain that the “warner is wakeing.” When Entertain J enters the space, the command influence channel shows Mr. B’s B/P balbutiation is 58/30 and the O2 sat is 79%. The resigned is connecttalented quick and no distinct pulse can be detected.

A STAT CODE is flattered and the son is escorted to the cessation space. The command team arrives and begins resuscitative efforts. When conjoined to the cardiac warner, Mr. B is origin to be in ventricular fibrillation. CPR begins instantly by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are directed. Following 30 minutes of interventions, the ECG avail to a regular sinus rhythm with a pulse and a B/P of 110/70. The resigned is connecttalented quick on his admit and is easily subject on the ventilator. The resigned’s pupils are unwandering and dilated. He has no voluntary movements and does connecttalented corcorrespond to confirmative stimuli. Air rapture is flattered and, upon the origin’s wishes, the resigned is transmitted to a tertiary address govern advanced wariness.

Slevel days following, the receiving hospital sensible the arcadian hospital that EEG’s had immovtalented brain release in Mr. B. The origin had requested life-livelihood be removed, and Mr. B following died.

Concomitant counsel: The hospital where Mr. B. was originally seen and treated had a jurisprudencerate sedation/analgesia (“conscious sedation”) system that requires that the resigned sweepings on normal B/P, ECG, and pulse oximeter throughquenched the rule and until the resigned meets specific send-away criteria (i.e., easily reassure, VSS, no N/V, and talented to nugatory). All practitioners who fulfil jurisprudencerate sedation must earliest auspiciously consummate the hospital’s jurisprudencerate sedation inoculation module. The inoculation module includes garbage excerption as courteous as accepttalented dose fixs. Concomitant (backup) staff was suited on the day of the distinct. Entertain J had consummated the jurisprudencerate sedation module. Entertain J had vulgar ACLS certification and was an conversant nice wariness entertain. Entertain J’s antecedent annual clinical evaluations by the director demonstrated that the entertain was “meeting requirements.” Entertain J did connecttalented keep a narrative of disorderly resigned wariness. Sufficient equipment was suited and in afloat ordain in the ED on this day.


A. Consummate a origin origin segregation (RCA) that takes into subsidy fruitful factors, errors, and/or hazards that led to the patrol episode (this resigned’s quenchedcome).

B. Discuss a way progress drawing that would retrench the probability of a reaffair of the quenchedcome of the scenario.
1. Discuss a diversify scheme that could be explanationd to instrument the way progress drawing patent clear in B.

C. Explanation a want jurisprudence and movabless segregation (FMEA) to contrivance the probability that the way progress drawing you insinuate would connecttalented miscarry.
1. Identify the limbs of the interdisciplinary team who get be comprised in the FMEA.
2. Discuss marchs govern preparing govern the FMEA.
3. Adduce the three marchs of the FMEA (severity, affair, and baffling defeat) to the way progress drawing created in multiply B.
4. Teach how you would proof the interventions from the way progress drawing from multiply B to reform wariness in a common beleagueruation.

Note:You are connecttalented expected to convey quenched the liberal FMEA, excluding you should teach each march, and how you would adduce it to your way progress drawing.

D. Discuss how the negotiative entertain may business as a guide in promoting capacity wariness and influencing capacity progress activities.

E. When you explanation origins to livelihood ideas and elements in a disquisition or contrivance, collect acknowledgement of origin counsel govern any gladdend that is quoted, paraphrased or summarized. Acknowledgement of origin counsel includes in-text quotation connectableing specifically where in the surrender the origin is explanationd and a identical intimation, which includes:
• Author
• Date
• Title
• Location of counsel (e.g., publisher, register, or website URL)

Note: The explanation of APA quotation title is encouraged excluding is connecttalented required govern this work. Evaluators get prproffer feedtail on the acknowledgement of origin counsel excluding connecttalented with value to regularity with APA or other quotation title. Govern tips on using APA title, gladden connect to the APA Resources web incorporate origin below General Counsel/APA Guidelines in the left-hand panel in WorkStream.

Note: No over than a thoroughly aggregate of 30% of a surrender can be quickly quoted or air-tight paraphrased from quenchedside origins, level if cited rightly.

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