Root Cause Analysis

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RTT1 TASK II VIRGINIA FISHER WESTERN GOVERNORS UNIVERSITY A/A1 Root Cause Analysis Root cause analysis would be a very important first step in considering what happened during and before the sentinel event with Mr. B. The sentinel event with Mr. B using the root-cause analysis would start by asking the “five whys” which will begin to sift through the event and begin to illuminate a cause for the event. In this scenario Mr. B’s situation became a sentinel event as a result of hypoxia following conscious sedation and ending in cardiac arrest and finally death. But the question is how was this allowed to occur? The clinical outcome in this situation was clearly that Mr. B was over-sedated leading to a very dangerous situation. Hypoxia during sedation is a common side affect, which is treated by giving the patient O2 or reversing the sedation. However in this situation the staff was not aware that he was hypoxic, and why weren’t they? The answer a nurse had silenced the alarm but had not done an assessment nor alerted anyone else of the situation. Why did the nurse choose to silence the alarm with no further action? It is very clear in this scenario that the ER had gotten very busy and the nurse was very likely overwhelmed and distracted. The quickest and easiest thing to do was to silence the alarm and move on. The next question that comes to mind is why was the patient not on ECG monitoring? Why had his respirations not been monitored? The nurse likely in her very busy state forgot to put him on the ECG monitor, or she may have not chosen to place him on a monitor. She may have chosen to not put him on a monitor because in her personal experience he was a low risk patient with a high narcotic tolerance. With the ER getting busier she thought she was saving herself a little bit of time by not placing him on the ECG monitor. Using the “five whys” to

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