Introduction:

Healthcare organizations accredited by the Joint Commission are required to conduct
a root cause analysis (RCA) in response to any sentinel event such as the one
described below. Once the cause is identified and a plan of action established, it is
useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood
that a process would fail. As a member of the healthcare team in the hospital
described in this scenario, you have been selected as a member of the team
investigating the incident.

Scenario:

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

Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88
(regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. 8. states
that he has no known allergies and no previous falls. He states, “My hip area and leg
hurt really bad. I have never had anything like this before.” Patient rates pain at ten
out of ten on the numerical verbal pain scale. He appears to be in moderate distress.
His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and
limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further
evaluated and discharged from triage to the emergency department (ED) patient
room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history
of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his
primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr.
B‘s current medications are atorvastatin and oxycodone for chronic back pain. After
the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of
admission findings and the ED physician proceeds to examine Mr. 8.

Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and
one emergency department physician. Respiratory therapy is in-house and available
as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients.
One patient is a 43-year-old female complaining of a throbbing headache. The patient
rates current pain at four out of ten on numerical verbal pain 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

 

 

After evaluation of Mr. 8, Dr. T, the ED physician, writes the order for Nurse J to
administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP
at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr.
B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The
medication (hydromorphone) is administered IVP at 4:15 p.m. After five minutes, Dr.
T is still not satisfied with the level of sedation Mr. B has achieved and instructs
Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of
diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle
relaxation from the diazepam, which will aid in the manual manipulation, relocation,
and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve
pain control and sedation. After reviewing the patient’s medical history, Dr. T notes
that the patient’s weight and current regular use of oxycodone appear to be making it
more difficult to sedate Mr. 8.
Finally at 4:25, the patient appears to be sedated and the successful reduction of his
(L) hip takes place. The patient appears to have tolerated the procedure and remains
sedated. He is not currently on any supplemental oxygen. The procedure concludes at
4:30 p.m. and Mr. B is resting without indications of discomfort and distress. At this
time, the ED receives an emergency dispatch call alerting the emergency department
that the emergency rescue unit paramedics are en route with a 75-year-old patient in
acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure
machine programmed to monitor his B/P every five minutes and a pulse oximeter. At
this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit with him as he
is being monitored via the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and
his 02 sat is 92%. He remains without supplemental oxygen and his ECG and
respirations are not monitored.
Nurse J and the LPN on duty have received the emergency transport patient. They
are also in the process of discharging the other two patients. Meanwhile, the ED
lobby has become congested with new incoming patients. At this time, Mr. B‘s 02
saturation alarm is heard and shows “low 02 saturation” (currently showing a sat of
85%). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P
reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress
patient, which includes assessments, evaluation, and the ordering respiratory
treatments, CXR, labs, etc.
At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor
is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr.
B’s B/P reading is 58/30 and the 02 sat is 79%. The patient is not breathing and no
palpable pulse can be detected.

 

 

 

A STAT CODE is called and the son is escorted to the waiting room. The code team
arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr.
B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr.
B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are
administered. After 30 minutes of interventions, the ECG returns to a normal sinus
rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and
is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has
no spontaneous movements and does not respond to noxious stimuli. Air transport is
called and, upon the family’s wishes, the patient is transferred to a tertiary facility
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for advanced care.
Seven days later, the receiving hospital informed the rural hospital that EEG’s had
determined brain death in Mr. B. The family had requested life-support be removed,
and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had
a moderate sedation/analgesia (“conscious sedation”) policy that requires that the
patient remains on continuous B/P, ECG, and pulse oximeter throughout the
procedure and until the patient meets specific discharge criteria (i.e., fully awake,
VSS, no N/V, and able to void). All practitioners who perform moderate sedation
must first successfully complete the hospital’s moderate sedation training module.
The training module includes drug selection as well as acceptable dose ranges.
Additional (backup) staff was available on the day of the incident. Nurse J had
completed the moderate sedation module. Nurse J had current ACLS certification and
was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by
the manager demonstrated that the nurse was “meeting requirements.” Nurse J did
not have a history of negligent patient care. Sufficient equipment was available and
in working order in the ED on this day.

 

 

Task:

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

8. Discuss a process improvement plan that would decrease the likelihood of a
reoccurrence of the outcome of the scenario.

1. Discuss a change theory that could be used to implement the process
improvement plan developed in B.

C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the
process improvement plan you suggest would not fail.

1. Identify the members of the interdisciplinary team who will be included in the
FMEA.

2. Discuss steps for preparing for the FMEA.

3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the
process improvement plan created in part B.

4. Explain how you would test the interventions from the process improvement
plan from part B to improve care in a similar situation.
Note:You are not expected to carry out the full FMEA, but you should explain
each step, and how you would apply it to your process improvement plan.

D. Discuss how the professional nurse may function as a leader in promoting quality
care and influencing quality improvement activities.

E. When you use sources to support ideas and elements in a paper or project,
provide acknowledgement of source information for any content that is quoted,
paraphrased or summarized. Acknowledgement of source information includes in-

text citation noting specifically where in the submission the source is used and a
corresponding reference, which includes:

0 Author

0 Date

Title

0 Location of information (e.g., publisher, journal, or website URL)