Root Cause Analysis:

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010). The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010). In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again. RCA is best done as soon as an adverse event has happened (Jacob, 2010). The first step in the RCA is to identify what had happened (Jacob, 2010). In the scenario, Mr. B was admitted to the Emergency Room (ER) after a fall. During the treatment, Mr. B was given
All the above causative factors have lead to the sentinel event which was Mr. B’s death. Errors from the scenario included, Mr. B was not monitored during the moderate sedation and his ECG was not monitored during the recovery from the sedation. The LPN who went in to turn off the alarm the first time also did not inform either Nurse J or Dr. T that Mr. B’s oxygen saturation was low. Additional staffs were available but no one was called to help on the floor when additional patients were admitted from the emergency dispatch. A. Process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario:

The main error from the scenario was that Mr. B was not on continuous blood pressure, ECG, and pulse oximeter monitoring throughout the moderate sedation process. The hospital does have a policy which requires anyone who is going through moderate sedation to be monitored until they meet certain discharge requirement; the policy was just not implemented at the time when Mr. B was admitted. The process improvement plan that I am proposing is to have all the staffs in the ER department to review the moderate sedation policy weekly. Nurses and doctors might be distracted by the patient load and forgets some details from the policy, but if everyone is aware of the policy, it increases the chances that other