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fx4020.docx ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan COURSE: NURSE-FPX4020 Improving Quality of Care and Patient Safety Root-Cause Analysis A sentinel ...

fx4020.docx ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan COURSE: NURSE-FPX4020 Improving Quality of Care and Patient Safety Root-Cause Analysis A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase œor the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance. An adverse drug event (ADE) is harm experienced by a patient resulting from exposure to a medication. Opioid analgesic use in the hospital setting is usually safe, but it is also associated with serious ADEs. (CAHM, 2013). This paper will describe in depth an example of a sentinel event utilizing opioids post- operative as well as explore the root-cause analysis of the medication error. Analysis of the Root Cause A 70-year-old man underwent a total hip replacement, which is typically a standard procedure. During surgery he received opioid analgesics, anesthetics, pain medication and a general anesthetic. While in the post-anesthesia care unit (PACU), he received an additional dosage o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . .

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