The paper aims at utilizing the Root Cause Analysis (RCA) model to investigate the reasons that lead to his unfortunate sentinel situation faced by Mr. B. In doing so, the paper will sufficiently examine all the events that caused the incident. In accomplishing these objectives, the change theory will be used as the framework for developing an improvement plan that would help in preventing the reoccurrence of such incidence. The Failure Modes and Effects Analysis (FMEA) will be utilized in ensuring the success of the improvement plan. Most importantly, an evaluation of the fundamental roles of nurses towards ensuring the provision of quality of patient care such as in Mr. B’s scenario will be done.
Root Cause Analysis
Root cause analysis (RCA) have been termed as representing the quest to identify those underlying or causal factors that usually cause performance discrepancies, which in turn result in a sentinel incident (Cherry & Jacob, 2013). In conducting a RCA for Mr. B’s case, the following will be the team members:
Dr. T who was present during the sentinel incidence as the emergency room physician
Nurses who were present (one RN and one LPN)
Emergency room nurse manager present
Hospital’s chief nursing officer (CNO)
The members will be expected to brainstorm the events that led to the situation, including possible errors and/or hazards. This will include finding out all the information regarding the case. Such could include recollecting the vital signs demonstrated by Mr. B during his hospitalization. Additionally, this will also include the documentation of pointing laboratory results such as elevated cholesterol and lipids levels, as well as the drugs he used.
Upon finishing the above, the team will need t...
... middle of paper ...
... this context, all nurses working in emergency rooms are required to be very attentive so that they are able to observe any slight warning that could produce results such as the one witnessed the unfortunate situation the patient in this case. Notably, the American Nurses Association (2010) emphasized that it is the sole responsibility of emergency room nurses to ensure continuous and diligent patient monitoring.
The paper has evaluated the causative factors of Mr.B’s sentinel situation using the root cause analysis. In the process, FMEA was utilized to safeguard the process improvement plan from the possibility of failing. Most importantly, nurses are being reminded from this case study that they have an important responsibility of ensuring quality care to patients so that the unfortunate situation that happened to Mr. B cannot be repeated to other patient
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