Organizational systems and Quality leadership. C489-Task 2-revised version
Gina Potter
000203903
Western Governor’s University
January 31, 2016, 2016

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will then be …show more content…

Another hazard would be having a licensed practical nurse (LPN), monitor and observe a patient who has undergone conscious sedation in an emergency room environment. Policy for managing a consciously sedated patient was there, it was unfortunately not used. A major hazard uncovered is why Mr.B not on continuous ECG or telemetry monitoring? We know that Mr.B was given 2 rounds of diazepam and hydromorphone with in a 15 minute time span, both known to cause drowsiness, sedation and lower rate of respirations. We also know from the initial triage assessment that Mr. B is on home Oxycodone for back pain. We do not have documented the last time he took it. Is this because the triage assessment was rushed due to short staffing? We do though know for sure the he has an active prescription of it and we know it is known to cause somnolence, so again, why was no one monitoring his respirations?
Upon analyzing the data, the RCA team looked at the causative factors, and events that led up to Mr. B’s death. The RCA team then determined that the ultimate root cause of Mr. B’s death was in fact a medication error. It was documented that Mr. B was in fact given an overdose of hydromorphone during