Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).
Competencies: 734.3.1: Principles of Leadership – The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings through the application of sound leadership principles.
734.3.2: Interdisciplinary Collaboration – The graduate applies theoretical principles necessary for effective participation in an interdisciplinary team.
734.3.3: Quality and Patient Safety – The graduate applies quality improvement processes intended to achieve optimal healthcare outcomes, contributing to and supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance – The graduate analyzes financial implications related to healthcare delivery, reimbursement, access, and national initiatives
Introduction:
Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.
Scenario:
It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of admission findings and the ED physician proceeds to examine Mr. B.
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