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NURS FPX4020 Assessment 2.docx NURS-FPX 4020 Root-Cause Analysis and Safety Improveme
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NURS FPX4020 Assessment 2.docx NURS-FPX 4020 Root-Cause Analysis and Safety Improvement Plan Caplella University NURS-FPX 4020 Root-Cause Analysis and Safety Improvement Plan Root-Cause Analys... is Root-Cause analysis is a problem-solving technique that aims to uncover the root cause of an issue, for it to be more understood and avoided in the future. When using the root-cause analysis (RCA) approach, issues related to patient safety can be explored in detail. Thomas and Zoe Quaid were twins being treated for a staph infection in a hospitals pediatric department in November of 2007. The twins were given a dose of Heparin that was 1,000 times stronger than what was supposed to administered. While they survived and were eventually reunited with their parents, this sentinel event is one that could have been potentially fatal. “An adverse drug event (ADE) is an injury resulting from medical intervention related to a drug. This broad term includes but is not limited to medication errors, adverse drug reactions, allergic reactions and overdoses†(Gordo et al., 2021). This paper will examine the Quaid event fully and will examine evidence-based solutions that could have helped avoid the incident. Analysis of the Root Cause “Physiological and developmental differences in children, the need for individual drug dosage based on childrens weight and their inability to communicate complaints can make them more vulnerable to the occurrence of harm in hospital settings†(Silva et al., 2020). This co. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]
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