C489 Task 2 A.Root Cause Analysis A root cause analysis is a systematic process for identifying “root causes†of problems or events and an approach for responding to them. (Risk & Reliability Division, ABS Group, I
...
C489 Task 2 A.Root Cause Analysis A root cause analysis is a systematic process for identifying “root causes†of problems or events and an approach for responding to them. (Risk & Reliability Division, ABS Group, Inc., 2017) The final outcome for this scenario is that Mr. B died an unnecessary death. Mr B. died due to the lack of oxygen to the brain and ventricular fibrillation. Upon initial assessment of Mr. B. His vital signs were within normal limits. His oxygen levels at that time were good enough that he didnt require supplemental oxygen. Mr. B was given an increased amount of sedation meds to block his pain which were a direct effect for decreased O2 levels and hypotension. Being in a very busy emergency room unexpected things happened and he was not given the proper attention for his current situation. In this scenario there were several causative agents for his death. Starting with the initial procedure The Dr prescribed 10mg of Diazepam and 4mg of Hydromorphone within a 20 minute period to be able to relax Mr. B so he can manipulate his hip. Dr. T did not allow enough time for the medication to take effect which caused any increase amount of sedation drugs to be given. The nurse nor the Dr. followed the sedation protocol until Mr. B met discharge criteria. Protocol for this facility was for the patient to be on continuous ECG, O2 and blood pressure monitoring. Staffing at this time was also a concern in this scenario. While Mr. B. was recovering 2 patients were waiting t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . .
[Show More]
