Rtt1 Essay

629 Words3 Pages
RTT1 Task 2 Jake McKee Western Governors University RTT1 Task 2 Root Cause Analysis (RCA) that led to sentinel event Root cause in this scenario appears to be a combination of things. Most significantly, staff did not safely adjust to rapidly increasing demands of their patient acuity and census. The infrastructure did not allow simultaneous monitoring of two patients in crisis. The department is at high risk of inundation, being staffed with only one RN and one LPN, one secretary, and one emergency department physician. Secondly, balance in the monitoring of high-risk patients was inadequate. Staff failed to implement additional monitoring for Mr. B. The patient needed extra monitoring due to had an increased dosage due to high tolerance to the prescribed sedatives. Leaving an untrained family member to attend to a patient in respiratory crisis was not only unsafe; it was in violation of established conscious-sedation protocol. Mr. B. was vulnerable when he was left unattended. Finally, the LPN on duty displayed a dangerous knowledge deficit by ignoring the de-saturation alarm on the oximeter. Improvement Plan Using Change Theory Change theory helps to effectively organize ideas that bring about long-term change. Implementing change theory first requires an identified driving force. In the scenario, Emergency department staff members were likely shaken by this poor outcome of Mr. B., and would be motivated to change to a safer model just to avoid a repeat in the future. Staff members may be reluctant to change because of established habits in patient flow. This reluctance to change would be an identifiable restraining force, which opposes process improvement. Implementing a model which allows for rapid, safe adjustment to increasing acuity would help avoid poor outcomes in the future. Follow-up is
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