For the case presented, complete a Root Cause Analysis and the following:
Determine the members for a multidisciplinary team that should be involved in the investigation
Fishbone Diagram to determine causal factors that contributed to the error
Recommend Corrective Actions and Next Steps, be sure to include immediate and long term solutions to improve patient safety
Conduct an FMEA on your corrective actions and determine if the actions chosen will reduce the likelihood of reoccurrence
Discuss if this event meets The Joint Commission definition for Sentinel Event and if it should be reported to them.
A 67-year-old male (Mr. B) was brought into the emergency room for pain to left leg and left hip. The injury occurred when the patient had a fall due to him losing his balance after tripping over his dog. The hospital is a 60-bed rural hospital located in Mr. B’s hometown. Mr. B was brought in by his son and neighbor. Upon triage Mr. B was complaining of pain 10/10 on the numerical pain scale and his vitals were found to be stable. Mr. B has a history of impaired glucose tolerance, prostate cancer, and chronic pain which he is on oxycodone. The Patient states he had no known allergies or previous falls. Upon the nursing assessment Nurse J. has noticed that the patient has limited range in motion, his left leg has swelling and appears shortened in comparison to the right.
Nurse J. has informed the ED physician which he came to his bedside for evaluation. Upon evaluation the physician decided that Mr. B needed to have a reduction of his left hip, due to the dislocation and will require a conscious sedation. Mr. B requires multiple doses of medication to achieve the desired sedation affect for the reduction. Once the reduction was successful Mr. B is left with son in the room where a full set of vitals were not continuously monitored and goes into respiratory failure which led to the death of Mr. B. Staffing on this day is the day of the event consisted of a secretary, emergency department physician (Dr. T), and two nurses (one RN and one LPN). A respiratory therapist is in house and available as needed in this six bed ED and sixty bed hospital.
Events
At 3:30pm- Mr. B was taken to ED for left leg and left hip pain from a fall. Pain is 10/10 vitals include 120/80 blood pressure (BP), 88 heart rate (HR) and regular, 98.6 temperature, (T), 32 respirations (R), 175 lbs. At 4:05pm- Mr. B was given Diazepam 5mg IVP which had no affect after 5min. At 4:10pm- Dr. T orders 2mg of hydromorphone to be given to Mr. B. At 4:15pm- Mr. B was given 2mg of hydromorphone IVP.
At 4:20pm- Dr. T is not satisfied with level of sedation and orders Mr. B to be given 2mg of hydromorphone, and diazepam 5mg IVP.
At 4:25pm- Mr. B appears to be sedated and reduction of his (L) hip takes place. The patient remains sedated and appears to have tolerated the procedure. The procedures concludes at 4:30pm. No distress is noted, patient is placed on monitor for blood pressure to be taken every 5 minutes along with pulse oximeter, but no supplemental oxygen or ECG leads (monitors cardiac rhythm and respirations) was placed on patient at this time.
At 4:30pm- Nurse J allows Mr. B’s son to remain in the room with him as he is being monitor by blood pressure machine only. Nurse J leaves the room.
At 4:35pm- Mr. B vitals are BP 110/62, O2 sat is 92% still no oxygen or ECG leads are on patient at this time. EMS is transporting a patient in respiratory distress; lobby is beginning to get congested.
LPN and Nurse J. in the process of discharging 2 patients and are checking in the patient that EMS has transported in. LPN enters Mr. B’s room and resets his alarming monitor that was showing a sat of 85% and restarts the B/P to recycle. LPN does not supply oxygen and does not alert Nurse J at this time. Management is not notified that patient acuity and patient load is increasing. Nurse J is now fully engaged with the emergency care of the respiratory distress patient.
At 4:43pm- Mr. B’s son comes out of room and informs the nurse that the monitor is alarming with vitas of B/P 80/58 O2 of 79%. The patient has no palpable pulse and is not breathing. A STAT code is called, and the son is taken to the waiting room.
The code teams arrives places Mr. B on cardiac monitor where he is in ventricular fibrillation and the team begins resuscitative efforts. CPR is started and the patient is intubated. Mr. B is defibrillated and reversal agents, vasopressors and IV were started. At 5:13pm- After 30 min of interventions the ECG returns to a normal sinus rhythm with Mr. B’s B/P being 110/70. The patient is completely dependent on the ventilator, his pupils are fixed and dilated and there is no spontaneous movements. The family as asked for the patient to be transferred out to a tertiary facility for further advanced care.
Seven Days later Mr. B has died. The family had requested that life-support be removed after brain death had been determined by EEG’s. This is a sentinel event.
We need at least 10 more requests to produce the answer.
0 / 10 have requested this problem solution
The more requests, the faster the answer.
CLIENT PROFILE Mr. Cohen is a 75-year-old male admitted with an exacerbation of chronic obstructive pulmonary disease (emphysema). He has been keeping the head of the bed up for most of the day and night to facilitate his breathing which has resulted in lower back pain. Acetaminophen was not effective in reducing his pain, so the health care provider has prescribed oxycodone/acetaminophen one to two tablets PO every four to six hours as needed for pain. Mr. Cohen is on...
Greta VanFleet is 24 hours post-op from a Right Knee Replacement. When you go in to do a pain assessment, Greta states her pain as a 8 on a 1-10 pain scale at 1700. Greta has an order for oxycodone 5mg/acetaminophen 325mg 1 to 2 tablets PO q6hrs PRN for moderate to sever pain. For what condition(s) is oxycodone indicated? For what conditions(s) is acetaminophen indicated? What is the usual recommended adult dosage range? What is the maximum recommended daily...
Tonya returns to Mr. Lawson's room to discuss his discharge instructions, but she notes as she enters the room that the patient is grimacing. She asks him, “Tell me where the pain is.” Mr. Lawson is asked to rate the pain on a scale of 0 to 10 and rates it a 6. Tonya looks at the patient's surgical wound and notes that the area of separation is still inflamed. Match the assessment technique on the left with the type...
Mr. J is a 62 year-old patient who has a history of GERD, Rheumatic Heart Disease, hyperlipidemia and hernia repair. His wife brought him to the Emergency Department for suspected stroke at 6:30pm this evening. Mrs. J states that her husband began complaining of a headache shortly before dinner. Additionally, during their meal, Mr. J was unable to pick up his fork and was having difficulty speaking. Initial VS are as follows: HR 112 a-fib, RR 28, SAT 92% on room air, BP 175/100, Temp...
1. Calculate the dose for the following medications: Order: codeine 30mg PO q4hr PRN for pain Supply: codeine 15mg scored tablets Give: _______________ tablets Order: Tylenol with codeine 15mg PO QD Supply: Tylenol with 7.5mg codeine unscored tablets Give: _____________ tablets 2. Stevie Nicks is a 79 year old women who was admitted to the orthopedic floor from the Emergency Department with a fractured hip from a fall. The doctor ordered to start 0.9% Sodium Chloride. Your order states: 500mL...
An 80 year-old male was transported by ambulance to the emergency department (ED) for evaluation after experiencing an unwitnessed fall in a local nursing home.The patient resided at the nursing home and had a medical history of severe dementia and osteoporosis.The patient arrived to the ED alone without family or staff from the local nursing home. Upon arrival to the ED, the patient was triaged by nursing staff. The triage documentation noted the patient’s vital signs were stable, that he...
Billy Franklin, a 17-year-old male was in a motor vehicle accident and transported to the ED by ambulance. He presented with SOB, bruising diagonally across chest, tachypnea, uneven rise and fall of chest with breaths, and confusion when asked where he is at. He stated that he has sharp stabbing chest pain and is “having a hard time breathing”. During initial assessment nurse noted crepitus upon auscultation. His vitals were blood pressure of 108/61, pulse rate of 112, O2 sat:...
Mr. Lewis is a 88-year old man brought to the emergency room by his daughter after finding him in his bedroom, lying on the floor beside his bed. Mr. Lewis is in obvious pain. He is wheeled into the ER by his daughter. He is moaning and rubbing his right leg. Pausing after every few words to catch his breath, he tells the nurse, “My leg is killing me. It keeps tightening and releasing. I cannot stand on it. It...
please use complete sentences . no bulletpoint answer Patient 1: M.J. is a 40-year-old female who had a mastectomy 3 days ago and has started on chemotherapy for stage 4 breast cancer. M.J. has a central line, a urinary catheter, and the surgical incision. She is alert and oriented. Her skin is flushed and hot to touch. Her vitals are: T 104, HR 110, RR 30, B/P 106/66. Hemodynamics are CO 5, CVP 3. EKG is sinus tachycardia per the...
An 80 year-old male was transported by ambulance to the emergency department (ED) for evaluation after experiencing an unwitnessed fall in a local nursing home. The patient resided at the nursing home and had a medical history of severe dementia and osteoporosis. Upon arrival to the ED, the patient was triaged by nursing staff. The triage documentation noted the patient’s vital signs were stable, that he was a poor historian and complained of “hurting all over”. After triage was completed,...