In the case of Mr. B’s, an investigation into the events surrounding to and leading up to his untimely death would be required. Once the problem has been identified and described, data of events are collected and formatted into a timeline. From the events, any problems in the care of the patient which may have contributed to the end result are identified and determined whether they are causative. In appendix A, the timeline of the event is outlined.
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
There was inappropriate staffing in the Emergency Room which was a factor in the event. There was one registered nurse (RN) and one licensed practical nurse (LPN) on duty at the time of the incident. Additional staff was available and not called in. The Emergency Nurses Association holds the position there should be two registered nurses whose responsibility is to prov...
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