C489 TASK 2
A bunch of notes and help to get your paper done!
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The Unfortunate Hospital Experience for Mr. B
Identification of Events
* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain
* His son is at the bedside
* Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside.
* Dr. T orders moderate sedation
* Mr. B takes oxycodone for chronic pain
* Nurse J is assigned to care for Mr. B
* Nurse J administers medications per Dr.T’s orders
* 5 mg of Diazepam
* Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation
* Dr. T orders additional sedation medication
* 2mg of Hydromorphone
* Nurse J administers additional sedation medication per Dr. T orders
* Mr. B …show more content…
Family withdraws care. Mr. B dies.
What should have happened?
* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain
, * His son is at the bedside
* Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside.
* Dr. T orders moderate sedation
* Mr. B takes oxycodone for chronic pain
* Nurse J administers medications per Dr. T orders
* Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation
* Dr. T reviews the moderate sedation protocol and the acceptable dose ranges of medications.
* Dr. T orders medications according to the protocol
* Nurse J administers sedation medication per Dr. T orders
* Dr. T assesses Mr. B.
* Mr. B is safely sedated for the procedure
* Dr. T reduces and sets Mr. B’s left hip
* Mr. B’s procedure is completed. He appears comfortable and remains sedated
* The Emergency Room receives an emergency dispatch call
* Pt in respiratory distress
* Nurse J needs to respond to the call.
* Nurse J puts a blood pressure cuff on Mr. B with cycles of 5 minutes, places the pulse oximeter, cardiac
monitor (ECG), and supplemental oxygen.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Organizational Systems and Quality Leadership
Task 2
Western Governors University
Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will
be done to prevent it from happening again and how will we know that the changes made will improve
the safety of the system. It takes into consideration causative factors, errors and hazards that led to a
A bunch of notes and help to get your paper done!
Show More
The Unfortunate Hospital Experience for Mr. B
Identification of Events
* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain
* His son is at the bedside
* Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside.
* Dr. T orders moderate sedation
* Mr. B takes oxycodone for chronic pain
* Nurse J is assigned to care for Mr. B
* Nurse J administers medications per Dr.T’s orders
* 5 mg of Diazepam
* Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation
* Dr. T orders additional sedation medication
* 2mg of Hydromorphone
* Nurse J administers additional sedation medication per Dr. T orders
* Mr. B …show more content…
Family withdraws care. Mr. B dies.
What should have happened?
* Mr. B presents to the Emergency Room with complaints of Left hip and leg pain
, * His son is at the bedside
* Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside.
* Dr. T orders moderate sedation
* Mr. B takes oxycodone for chronic pain
* Nurse J administers medications per Dr. T orders
* Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation
* Dr. T reviews the moderate sedation protocol and the acceptable dose ranges of medications.
* Dr. T orders medications according to the protocol
* Nurse J administers sedation medication per Dr. T orders
* Dr. T assesses Mr. B.
* Mr. B is safely sedated for the procedure
* Dr. T reduces and sets Mr. B’s left hip
* Mr. B’s procedure is completed. He appears comfortable and remains sedated
* The Emergency Room receives an emergency dispatch call
* Pt in respiratory distress
* Nurse J needs to respond to the call.
* Nurse J puts a blood pressure cuff on Mr. B with cycles of 5 minutes, places the pulse oximeter, cardiac
monitor (ECG), and supplemental oxygen.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Organizational Systems and Quality Leadership
Task 2
Western Governors University
Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will
be done to prevent it from happening again and how will we know that the changes made will improve
the safety of the system. It takes into consideration causative factors, errors and hazards that led to a
