Healthcare organizations accredited by the Join” rel=”nofollow”>int Commission are required to conduct a root cause analysis (RCA) in” rel=”nofollow”>in response to any sentin” rel=”nofollow”>inel 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” rel=”nofollow”>in the hospital described in” rel=”nofollow”>in this scenario, you have been selected as a member of the team in” rel=”nofollow”>investigatin” rel=”nofollow”>ing the in” rel=”nofollow”>incident.


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 moanin” rel=”nofollow”>ing and complain” rel=”nofollow”>inin” rel=”nofollow”>ing of severe pain” rel=”nofollow”>in to his (L) leg and hip area. He states he lost his balance and fell after trippin” rel=”nofollow”>ing 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 anythin” rel=”nofollow”>ing like this before.” Patient rates pain” rel=”nofollow”>in at ten out of ten on the numerical verbal pain” rel=”nofollow”>in scale. He appears to be in” rel=”nofollow”>in moderate distress. His (L) leg appears shortened with swellin” rel=”nofollow”>ing (edema in” rel=”nofollow”>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 admittin” rel=”nofollow”>ing nurse fin” rel=”nofollow”>inds 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” rel=”nofollow”>in and oxycodone for chronic back pain” rel=”nofollow”>in. After the nurse completes Mr. B’s assessment, Nurse J in” rel=”nofollow”>informs the ED physician of admission fin” rel=”nofollow”>indin” rel=”nofollow”>ings and the ED physician proceeds to examin” rel=”nofollow”>ine Mr. B.

Staffin” rel=”nofollow”>ing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in” rel=”nofollow”>in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is carin” rel=”nofollow”>ing for two other patients. One patient is a 43-year-old female complain” rel=”nofollow”>inin” rel=”nofollow”>ing of a throbbin” rel=”nofollow”>ing headache. The patient rates current pain” rel=”nofollow”>in at four out of ten on numerical verbal pain” rel=”nofollow”>in scale. The patient states that she has a history of migrain” rel=”nofollow”>ines. She received treatment, remain” rel=”nofollow”>ins stable, and discharge is pendin” rel=”nofollow”>ing. The second patient is an eight-year-old boy bein” rel=”nofollow”>ing evaluated for possible appendicitis. Laboratory results are pendin” rel=”nofollow”>ing for this patient. Both of these patients were examin” rel=”nofollow”>ined, evaluated, and cared for by the ED physician and are awaitin” rel=”nofollow”>ing further treatment or orders.

After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to admin” rel=”nofollow”>inister diazepam 5 mg IVP to Mr. B. The medication diazepam is admin” rel=”nofollow”>inistered IVP at 4:05 p.m. After five min” rel=”nofollow”>inutes, the diazepam appears to have had no effect on Mr. B, and Dr. T in” rel=”nofollow”>instructs Nurse J to admin” rel=”nofollow”>inister hydromorphone 2 mg IVP. The medication (hydromorphone) is admin” rel=”nofollow”>inistered IVP at 4:15 p.m. After five min” rel=”nofollow”>inutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and in” rel=”nofollow”>instructs Nurse J to admin” rel=”nofollow”>inister another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in” rel=”nofollow”>in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was admin” rel=”nofollow”>inistered to achieve pain” rel=”nofollow”>in control and sedation. After reviewin” rel=”nofollow”>ing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be makin” rel=”nofollow”>ing it more difficult to sedate Mr. B.

Fin” rel=”nofollow”>inally at 4:25, the patient appears to be sedated and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remain” rel=”nofollow”>ins sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr. B is restin” rel=”nofollow”>ing without in” rel=”nofollow”>indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alertin” rel=”nofollow”>ing the emergency department that the emergency rescue unit paramedics are en route with a 75-year-old patient in” rel=”nofollow”>in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machin” rel=”nofollow”>ine programmed to monitor his B/P every five min” rel=”nofollow”>inutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit with him as he is bein” rel=”nofollow”>ing monitored via the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remain” rel=”nofollow”>ins without supplemental oxygen and his ECG and respirations are not monitored.

Nurse J and the LPN on duty have received the emergency transport patient. They are also in” rel=”nofollow”>in the process of dischargin” rel=”nofollow”>ing the other two patients. Meanwhile, the ED lobby has become congested with new in” rel=”nofollow”>incomin” rel=”nofollow”>ing patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showin” rel=”nofollow”>ing a sat of 85%). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P readin” rel=”nofollow”>ing.

Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which in” rel=”nofollow”>includes assessments, evaluation, and the orderin” rel=”nofollow”>ing respiratory treatments, CXR, labs, etc.

At 4:43, Mr. B’s son comes out of the room and in” rel=”nofollow”>informs the nurse that the “monitor is alarmin” rel=”nofollow”>ing.” When Nurse J enters the room, the blood pressure machin” rel=”nofollow”>ine shows Mr. B’s B/P readin” rel=”nofollow”>ing is 58/30 and the O2 sat is 79%. The patient is not breathin” rel=”nofollow”>ing and no palpable pulse can be detected.

A STAT CODE is called and the son is escorted to the waitin” rel=”nofollow”>ing room. The code team arrives and begin” rel=”nofollow”>ins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in” rel=”nofollow”>in ventricular fibrillation. CPR begin” rel=”nofollow”>ins immediately by the RN, and Mr. B is in” rel=”nofollow”>intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are admin” rel=”nofollow”>inistered. After 30 min” rel=”nofollow”>inutes of in” rel=”nofollow”>interventions, the ECG returns to a normal sin” rel=”nofollow”>inus rhythm with a pulse and a B/P of 110/70. The patient is not breathin” rel=”nofollow”>ing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and, upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.

Seven days later, the receivin” rel=”nofollow”>ing hospital in” rel=”nofollow”>informed the rural hospital that EEG’s had determin” rel=”nofollow”>ined brain” rel=”nofollow”>in death in” rel=”nofollow”>in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.

Additional in” rel=”nofollow”>information: The hospital where Mr. B. was origin” rel=”nofollow”>inally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remain” rel=”nofollow”>ins on contin” rel=”nofollow”>inuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation train” rel=”nofollow”>inin” rel=”nofollow”>ing module. The train” rel=”nofollow”>inin” rel=”nofollow”>ing module in” rel=”nofollow”>includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the in” rel=”nofollow”>incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clin” rel=”nofollow”>inical evaluations by the manager demonstrated that the nurse was “meetin” rel=”nofollow”>ing requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in” rel=”nofollow”>in workin” rel=”nofollow”>ing order in” rel=”nofollow”>in the ED on this day.


A. Complete a root cause analysis (RCA) that takes in” rel=”nofollow”>into consideration causative factors, errors, and/or hazards that led to the sentin” rel=”nofollow”>inel event (this patient’s outcome).

B. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario.
1. Discuss a change theory that could be used to implement the process improvement plan developed in” rel=”nofollow”>in B.

C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
1. Identify the members of the in” rel=”nofollow”>interdisciplin” rel=”nofollow”>inary team who will be in” rel=”nofollow”>included in” rel=”nofollow”>in the FMEA.
2. Discuss steps for preparin” rel=”nofollow”>ing for the FMEA.
3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in” rel=”nofollow”>in part B.
4. Explain” rel=”nofollow”>in how you would test the in” rel=”nofollow”>interventions from the process improvement plan from part B to improve care in” rel=”nofollow”>in a similar situation.

Note:You are not expected to carry out the full FMEA, but you should explain” rel=”nofollow”>in each step, and how you would apply it to your process improvement plan.

D. Discuss how the professional nurse may function as a leader in” rel=”nofollow”>in promotin” rel=”nofollow”>ing quality care and in” rel=”nofollow”>influencin” rel=”nofollow”>ing quality improvement activities.

E. When you use sources to support ideas and elements in” rel=”nofollow”>in a paper or project, provide acknowledgement of source in” rel=”nofollow”>information for any content that is quoted, paraphrased or summarized. Acknowledgement of source in” rel=”nofollow”>information in” rel=”nofollow”>includes in” rel=”nofollow”>in-text citation notin” rel=”nofollow”>ing specifically where in” rel=”nofollow”>in the submission the source is used and a correspondin” rel=”nofollow”>ing reference, which in” rel=”nofollow”>includes:
• Author
• Date
• Title
• Location of in” rel=”nofollow”>information (e.g., publisher, journal, or website URL)

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