RTT1 Task 2
Organizational Systems and Quality Leadership
Western Governors University
Leslie Baylor

A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome).

“A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ,
2012). The prevention of errors is the main emphasis of a RCA. The process begins with gathering data in regards to the event, then the data needs to be analyzed, and the final step is to find solutions to the errors that were found so that a reoccurrence of the same error doesn’t occur again. The team should
leaves the room to start the new critical patient and is attempting to discharge her initial two patients. Vitals at 10 minutes after the end of sedation and reduction are a BP pf 110/62 and a pox of 92, he remained without RR and ECG monitoring. Just his son remains at the bedside. Mr. B’s alarms go off and is heard by the LPN, the alarm shows a low Pox of 85% and the LPN resets the alarm and rechecks the patients BP. The LPN requires more training in blood pressure monitor & Pox readings and when the RN or MD should be notified, along with training on appropriate interventions if the readings are low or high. If the appropriate training and interventions would have been done, the fatal event that occurred to Mr. B may have been prevented. Nurse J., the LPN, and the MD continued to see new patients and discharge patients home. Mr.
B per the scenario is not reevaluated by the RN or MD after the sedation or procedure, as required by policy. The alarm sounds again and Mr. B’s son comes out of the room to notify
Nurse J. Upon arrival she notes that Mr. B’s BP is critically low at 58/30 and his Pox reading is
79%.

There is no pulse noted and the patient is not breathing, a code is called for recitation

efforts. The patient when connected to the ECG is found to be in ventricular fibrillation (v-fib).
It takes 30 minutes to obtain a normal heart rhythm, but Mr. B. is intubated and needs the ventilator to breath. Mr.