Root Cause Analysis: Sentinel Events

RTT Task 2
Western Governors University

Sentinel events are never something healthcare workers or facilities want to have occur. If an unfortunate event does take place, it is necessary to properly investigate the situation in hopes to learn from the event and hinder another episode. The following will discuss procedures used to investigate sentinel events such as root cause analysis, change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions.
A. Root Cause Analysis Nursing is a profession of helping others. Those who choose to work in healthcare never intended on harming. However, if harm does come to a patient proper policy and procedure should be followed after
Respiratory Therapy is on staff, not present, but available if needed. When Mr. B arrived he made the third patient in a six bed Emergency Department. Additional back-up staff was available if needed. Policy for nurse to patient ratio for the facility is unknown however one on one care should have been addressed with the potential for respiratory depression with Mr. B. Additional staff were available to care for the incoming patients but were not utilized. With the issue of one on one care for conscious sedation if the only concern was respiratory related the in-house respiratory therapist could have been paged to monitor Mr. B while Nurse J was caring for other patients. Knowing Mr. B’s medication history of oxycodone use for chronic pain and the added medication for sedation would most definitely qualify him for one on one care until discharge criteria were met due to the potential for respiratory depression. With the added stressors of an additional critical patient arriving for care and multiple patients with need to be seen in the Emergency Department lobby the back up staff should have been
Nurses need to be effective with their critical thinking skills and utilize the resources at hand. Using base knowledge to prevent catastrophic events from occurring, such as the potentiation effect of medication. Knowing ,when we as nurses, have met our ability to perform effectively and need assistance is not only important for our well being but the well being of the patient and the organization as a whole. Integrating teamwork in the patient care effort not only builds a solid foundation for the organization but also for the positive outcome of the patient being treated. If for some unfortunate reason an adverse event does occur nurses must remember they “provide valuable insights into care processes when working with patient safety leaders as part of a root cause analysis team. Nurses ' unique knowledge of the care provided is essential for designing the best improvements in care processes” (Hall, Moore, & Barnsteiner, 2008). Probably among the most import ways a nurse can improve quality of care is his/her own self care. This can be done in many ways. Meditation for stress reduction, continuing education for confidence in patient care, are just a few examples. Having a rested, positive, confident attitude when preparing and performing patient care can make difference and help her do no harm and give the utmost quality of care to each patient she/he comes in contact