Western Governors University Organizational Systems And Quality Leadership


Healthcare organizations accredited by the Joint Commission arerequired to conduct a root cause analysis (RCA) in response to anysentinel event such as the one described below. Once the cause isidentified and a plan of action established, it is useful toconduct a failure mode and effects analysis (FMEA) to reduce thelikelihood that a process would fail. As a member of the healthcareteam in the hospital described in this scenario, you have beenselected as a member of the team investigating the incident.


It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient,arrives at the six-room emergency department (ED) of a sixty-bedrural hospital. He has been brought to the hospital by his son andneighbor. At this time, Mr. B is moaning and complaining of severepain to his (L) leg and hip area. He states he lost his balance andfell after tripping over his dog.

Mr. B was admitted to the triage room where his vital signs wereB/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight wasrecorded at 175 pounds. Mr. B. states that he has no knownallergies and no previous falls. He states, “My hip area and leghurt really bad. I have never had anything like this before.”Patient rates pain at ten out of ten on the numerical verbal painscale. He appears to be in moderate distress. His (L) leg appearsshortened with swelling (edema in the calf), ecchymosis, andlimited range of motion (ROM). Mr. B’s leg is stabilized and thenhe is further evaluated and discharged from triage to the emergencydepartment (ED) patient room. He is admitted by Nurse J. Theadmitting nurse finds that Mr. B has a history of impaired glucosetolerance and prostate cancer. At Mr. B’s last visit with hisprimary care physician, laboratory data revealed elevatedcholesterol and lipids. Mr. B’s current medications areatorvastatin and oxycodone for chronic back pain. After the nursecompletes Mr. B’s assessment, Nurse J informs the ED physician ofadmission findings and the ED physician proceeds to examine Mr.B.

Staffing on this day consists of two nurses (one RN and one LPN),one secretary, and one emergency department physician. Respiratorytherapy is in-house and available as needed. At the time of Mr. B’sarrival, the ED staff is caring for two other patients. One patientis a 43-year-old female complaining of a throbbing headache. Thepatient rates current pain at four out of ten on numerical verbalpain scale. The patient states that she has a history of migraines.She received treatment, remains stable, and discharge is pending.The second patient is an eight-year-old boy being evaluated forpossible appendicitis. Laboratory results are pending for thispatient. Both of these patients were examined, evaluated, and caredfor by the ED physician and are awaiting further treatment ororders.

After evaluation of Mr. B, Dr. T, the ED physician, writes theorder for Nurse J to administer diazepam 5 mg IVP to Mr. B. Themedication diazepam is administered IVP at 4:05 p.m. After fiveminutes, the diazepam appears to have had no effect on Mr. B, andDr. T instructs Nurse J to administer hydromorphone 2 mg IVP. Themedication (hydromorphone) is administered IVP at 4:15 p.m. Afterfive minutes, Dr. T is still not satisfied with the level ofsedation Mr. B has achieved and instructs Nurse J to administeranother 2 mg of hydromorphone IVP and an additional 5 mg ofdiazepam IVP. The physician’s goal is for the patient to achieveskeletal muscle relaxation from the diazepam, which will aid in themanual manipulation, relocation, and alignment of Mr. B’s hip. Thehydromorphone IVP was administered to achieve pain control andsedation. After reviewing the patient’s medical history, Dr. Tnotes that the patient’s weight and current regular use ofoxycodone appear to be making it more difficult to sedate Mr.B.

Finally at 4:25, the patient appears to be sedated and thesuccessful reduction of his (L) hip takes place. The patientappears to have tolerated the procedure and remains sedated. He isnot currently on any supplemental oxygen. The procedure concludesat 4:30 p.m. and Mr. B is resting without indications of discomfortand distress. At this time, the ED receives an emergency dispatchcall alerting the emergency department that the emergency rescueunit paramedics are en route with a 75-year-old patient in acuterespiratory distress. Nurse J places Mr. B on an automatic bloodpressure machine programmed to monitor his B/P every five minutesand a pulse oximeter. At this time Nurse J leaves his room. Thenurse allows Mr. B’s son to sit with him as he is being monitoredvia the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 andhis O2 sat is 92%. He remains without supplemental oxygen and hisECG and respirations are not monitored.

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