Question

Margaret is an elderly woman who has been admitted to a medical center for breathing problems. She has some trouble hearing and has some memory problems as well.

Peter is a well-respected nurse on a medical unity. He has been working there for five years and he has recently been helping new nurses get oriented to working in his part of the hospital. Today he is working with Amy, a new graduate who just passed NCLEX and received her RN.

Jorge, a respiratory therapist, is called to see Margaret to help with her breathing. He notes that she is not getting enough oxygen using the nasal prongs and he switches her to an oxygen mask, which improves her symptoms. Jorge sees Peter in the hallway and says, “Hey Peter I just upped her oxygen” as they pass in the hallway to their next tasks. It is a busy day for Jorge, so he figures he will write his notes in the chart later.

At 3pm Margaret is scheduled to go for a test in the radiology department on the other side of the hospital. Teddy, the patient transporter, arrives to take Margaret to her test. Peter, the nurse, is in another patient room assisting one of the doctors with the placement of a sterile central line. When Teddy asks if there are any special concerns with Margaret, Amy, the new nurse, replies, “No, she is all set.” If Amy had been told about Margaret’s oxygen mask, she would have accompanied her to the test.

While being transported, Margaret knocks her mask off her face. When she arrives in the radiology department for her test, she is not breathing. The code team is called, but they are not able to revive her

Question:

Write a Root Cause Analysis and corrective action for the clinical event.

Answer 1

The root cause of this unacceptable condition is- negligence. We nurses deal with the life of the patient's . We cannot play with it . Our core responsibility is to save the life of patient . Here two of the registered nurse Jorge and Peter are the culprits . It's their negligence that has taken the patient's life . First of all Jorge havnot documented about the oxygen mask , second when teddy asks Peter about any special concerns Peter replies No ,she is all set which was the big mistake done by Peter even Jorge has told him that he has increased oxygen rate in the hallway .

This is a matter of a life ,a family member who came to you with the trust that there I will get better care and the patient dies just because of the negligence of the healthcare providers . This is against ethics and the nurses should be terminated and punished for the misconduct they did