Running Head: C489 TASK 2 1
Organizational Systems and Quality Leadership
Task 2
WGU
, TASK 2 2
A. Root Cause Analysis
A root cause analysis (RCA) is an approach used in healthcare to answer what happened,
why did it happen and how to prevent it from happening again in response to an error that has
occurred [Ins10]. In the provided scenario Mr. B ultimately died as a result of receiving sedation
in the emergency and subsequently going into cardiopulmonary arrest. Several factors
contributed to this outcome.
Factors that had a causative effect on this outcome include, too much sedation over a
short period of time. The patient received a total of 4 mg of hydromorphone and 10 mg diazepam
in a 15-minute span. The onset time of hydromorphone is 10-15 minutes with a peak time of 15-
30 minutes and diazepam has an onset of 1-5 minutes with a peak time of 15-30
minutes[UnkND]. The patient was never placed on ECG monitor as per policy to detect any
decreased heart rate or abnormal heart rhymes that may occur with conscious sedation. No
supplemental oxygen was provided to the patient during or immediately after sedation despite
the increased risk of hypoxia with sedation. There was no nurse monitoring the patient after
sedation. The patient simply remained on continuous B/P and pulse oximeter. There was no
monitoring of respirations or ECG. Policy states patient is to remain on continuous B/P, ECG,
and pulse oximeter throughout procedure and until patient meets specific discharge criteria (fully
awake, VSS, no N/V and able to void). And finally when the LPN responded to the low O2
saturation alarm and finding the patients oxygen level at 85% this abnormal finding was not
reported to RN or doctor so appropriate action could have been taken.
Errors that contributed to the outcome include, not enough staff to appropriately care for
amount and type of patients. There was only1 RN and 1 LPN on duty with 3 patients in the
emergency room at the time Mr. B was sedated and they were getting a 4th emergency patient
Organizational Systems and Quality Leadership
Task 2
WGU
, TASK 2 2
A. Root Cause Analysis
A root cause analysis (RCA) is an approach used in healthcare to answer what happened,
why did it happen and how to prevent it from happening again in response to an error that has
occurred [Ins10]. In the provided scenario Mr. B ultimately died as a result of receiving sedation
in the emergency and subsequently going into cardiopulmonary arrest. Several factors
contributed to this outcome.
Factors that had a causative effect on this outcome include, too much sedation over a
short period of time. The patient received a total of 4 mg of hydromorphone and 10 mg diazepam
in a 15-minute span. The onset time of hydromorphone is 10-15 minutes with a peak time of 15-
30 minutes and diazepam has an onset of 1-5 minutes with a peak time of 15-30
minutes[UnkND]. The patient was never placed on ECG monitor as per policy to detect any
decreased heart rate or abnormal heart rhymes that may occur with conscious sedation. No
supplemental oxygen was provided to the patient during or immediately after sedation despite
the increased risk of hypoxia with sedation. There was no nurse monitoring the patient after
sedation. The patient simply remained on continuous B/P and pulse oximeter. There was no
monitoring of respirations or ECG. Policy states patient is to remain on continuous B/P, ECG,
and pulse oximeter throughout procedure and until patient meets specific discharge criteria (fully
awake, VSS, no N/V and able to void). And finally when the LPN responded to the low O2
saturation alarm and finding the patients oxygen level at 85% this abnormal finding was not
reported to RN or doctor so appropriate action could have been taken.
Errors that contributed to the outcome include, not enough staff to appropriately care for
amount and type of patients. There was only1 RN and 1 LPN on duty with 3 patients in the
emergency room at the time Mr. B was sedated and they were getting a 4th emergency patient
