Root cause analysis and conscious sedation

The team needs to focus on interventions that improve, decrease or prevent issues related to patient safety. BTS guidelines for emergency oxygen use in adult patients. The nurses would be required to do a medication reconciliation, emergency physician would review and pharmacy would calculate dosing depending on patients history, and medications.

B to do her assessments and monitoring that is required with moderate sedation policy, that she was trained in.

The goal is to eliminate those issues that happen more often and have a huge effect on patient safety. The relative risk of failure and its effects is determined by three factors: Disruptive Behavior Medical errors are fostered by intimidating and disruptive behaviors. The guidelines need to explain the roles of staff members, how often the committee meets, and explain the objectives.

Patterns of unexpected in-hospital deaths: a root cause analysis

Adopt a standardized form to use for collecting the home medication list and for reconciling the variances includes both electronic and paper-based forms. The emergency room nurse can implement a plan of care to assess and monitor the patient.

This information should include pediatric research study data, pediatric growth charts, normal vital sign ranges for children, emergency dosage calculations, and drug reference materials with information about minimum effective doses and maximum dose limits.

After implementation, continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events.

The emergency nurse could present educational opportunities for staff about changes made to moderate sedation policy and procedures. The emergency room nurse has the opportunity to become involved in committees that focus on quality improvement process and to educate other nurses and ancillary staff in the emergency room.

PS Lesson 2: Moderate sedation is designed to alter the level of consciousness of the patient while enabling the patient to maintain independently a patent airway Pinto, Bhimani, Milne, and Nicholson, Functions should be written in verb-noun context.

The physician and the nurse failed to realize that a combination of sedation drugs such as Valium and Dilaudi could have adverse effects on the patient.

Arousal failure allows precipitous hypoxemia during apnea causing terminal arousal arrest.

Organizational Systems and Quality Leadership Essay Sample

Tripple doses of intravenous valium and dilaudid were given without a lapse in time. The need to alter the original medication dosage requires a series of pediatric-specific calculations and tasks, each significantly increasing the possibility of error.

Flow charts with detailed information showing the progression of events that took place to help transition to the next phases of the process. These diagnostic misattributions have perpetuated misunderstandings among well intended clinicians from many specialties including Anesthesiology, Pulmonary Medicine, Critical Care, and Palliative Medicine.

There was thus a communication failure as the LPN failure to communicate the dropping O2 levels to the nurse and the physician led to his drastic deterioration of health.

FMEA looks at the process of patient care and takes a multidisciplinary team to look at a the process from a Quality improvements. Columns completed in step 7: The emergency nurse could meet with pharmacy to educate staff on dangerous and possible side effects of administering opioids and sedative medications.

The three components that make up the RPN are occurrence, or how often the error is likely to happen, detection, if the error occurs how likely will it be identified and severity, how severe is the error if it were to occur Failure Mode and Effect Analysis.

Defining the topic is the first step in the process, and then the team has to be created which should consist of about six to ten members. AORN Journal, 95 4The team should review each failure mode and identify potential effects of the failure, should it occur.

At sixty-seven years old and with a diagnosis of hypertension it is possible that there was a circulation issue. The emergency room nurse in this scenario has the opportunity to change the outcome and safety of patients. Provide feedback, on-going monitoring.

Root Cause Analysis A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob,p.

). In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. The Root Cause Analysis. Causative factors- (why it happened) determined cause.

Individual’s cause factors. Nurse J did not follow procedure for conscious sedation. The patient was not placed on continuous B/P, ECG, and pulse oximeter throughout the procedure.

Respiratory Therapist was not informed of the conscious sedation. The aim of this assignment is to conduct a root cause analysis of Mr. B.

Patterns of unexpected in-hospital deaths: a root cause analysis

The patient, Mr. B. arrived at the emergency room with a dislocated left shoulder after a fall in the shower. The medical practitioner put him through moderate sedation and relocated the shoulder. Define Root Cause Analysis, For example, frequent monitoring instituted for conscious sedation procedures does not reduce the risk of the sedation being too deep.

However, it allows early intervention to reverse the sedation and provide adequate oxygenation.

Root Cause Analysis of a Sentinel Event Essay Sample

Medical errors are fostered by intimidating and disruptive behaviors. Left. A root cause analysis is conducted to determine the cause or factors that contributed to the sentinel event. A few things must be asked in the RCA such as who, what, where, why and how in order to identify the cause.

Within 10 days the conscious sedation procedure should be evaluated by a committee to ensure the best practices are being.

Root cause analysis and conscious sedation
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Organizational Systems and Quality Leadership | Essay Example