Case Study on "Root Cause Analysis"
Case Study 5 pages (1329 words) Sources: 5
[EXCERPT] . . . .
health care environment, the complexities and variabilities of the human condition, when combined with individuals, stress, environmental events, and general work issues has the potential for negative effects. These effects may be from human or mechanical error, or simply the lack of control we hold over biological systems. Using root cause investigative procedures, a determination can be made in a relatively detailed manner what events, no matter how unlikely, occurred to cause the failure. A thorough investigation into these causes is necessary in order to prevent similar occurrences. The basic methodology can be used in numerous ways: in business, education, and in medicine. In most cases, however, there are multiple approaches to resolution; and often require difference levels of resources to solve (Latino, 2006).In the medical scenario under review, Mr. B, a 67-year-old patient with a history of impaired glucose tolerance, prostate cancer, and chronic back pain, is admitted for extreme pain in his left leg. Because of his tolerance to the oxycodone for his back pain, it was quite difficult to get him sedated. Due to the ER becoming quite busy, Mr. B was placed in a room and stabilized, but had to have his alarm reset because of a low O2 saturation level. Within 10 minutes of resetting, Mr. B's son alerts the nurse that something is wrong. A STAT CODE is called, and Mr. B is intubated, defibrillated and given vasopressors. After 30 minutes of interventions, the ECG returns to normal, but the patient remains dependent upon the ventilator. He is transported to an advanced care facility where, in 7 days, is determined to be brain dead and, upon the family's request, life support is removed.
download full paper ⤓
Looking at Mr. B's situation, we can find several potential causations for his bodily reaction: drug interaction, excessive use of pain medication to allow for procedure, lack of optimal monitoring, and potential misreading of severity of symptoms:
Issue
Tactics
Strategic
Potential Results
Pain Meds
Diazepam, Hydromorphone
Needed to get patient sufficiently relaxed and mobile for manipulation of leg
Oxycodone has had potentially negative and life-threatening interaction's with diazepam, and when combined with morphine products is actually quite dangerous (Drug Interactions Between Oxycodone and Diazapam, 2011)
Supplemental O2
Not given
Physician saw no need
Supplemental O2 might have mitigated some of the combination effects of the three pain meds.
ECG/Respiration Monitor
Not used
Physician saw no need
Because of the previous health history, ECG and Respiration monitoring were desirous
Time Management
Busy ER
Staffing
Staff cannot control cases or number of patients; technological monitoring might have saved time in this case; as would have more careful realization about drug interaction.
Part 2 -- Change Theory -- at its most basic level, change theory takes a situation and changes it so that the results received are not repeated. There are actually a few relatively easy issues that would contribute to the mitigation of this scenario:
Change the approach to pharmaceutical combination -- a combination of hydrocodone, diazepam, and oxycodone was the cocktail that contributed to the death of Heath Ledger, and was very well publicized nationally. In addition, most physicians should be aware of the potentials for drop in BP and respiratory failure. Diligence would be called for regarding giving any pain killers to patients who are on medium to high doses of oxycodone.
Change the approach to electronic monitoring -- as the ER became busier, electronic monitoring of patient would seem logical. Staff cannot be in four places at once; but additional monitoring would have likely caused enough alarm that resuscitation could begin earlier; especially after first warning.
Change the approach to patient history issue; prostate cancer and chronic back pain typically require numerous medications, physician should constantly be aware of interactions within new patients (Tiffany and Lutjens, 1998).
Part 3- Failure Mode and Effect Analysis -- a procedure to analyze system failures, or likelihood of said failures. In this case, because the patient was removed from life-support after being brain dead, enough… READ MORE
Quoted Instructions for "Root Cause Analysis" Assignment:
“***** A Case Study will be uploaded as a resource.
***** A pdf file resource to help do a root cause analysis will be uploaded.
1. Complete a ROOT CAUSE ANALYSIS (RCA) that takes into consideration causative factors that led to the sentinel event (this patient*****'s outcome). Be sure to discuss errors or hazards in care in this scenario.
2. Use CHANGE THEORY to develop an improvement plan to decrease the likelihood of a reoccurrence of the outcome or the scenario.
3. Use FAILURE MODE AND EFFECTS ANALYSIS (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
a. Identify the members of the interdisciplinary team who will be included in the RCA and FMEA.
b. Explain how you would test any interventions to improve care in a similar situation by changing the process of care.
c. Discuss pre-steps for preparing for the FMEA.
d. Describe THREE steps of the FMEA: severity, occurrence, and detection.
4. Discuss the key role nurses would play in improving the quality of care in this situation. *****
How to Reference "Root Cause Analysis" Case Study in a Bibliography
“Root Cause Analysis.” A1-TermPaper.com, 2011, https://www.a1-termpaper.com/topics/essay/health-care-environment-complexities/2162. Accessed 1 Jul 2024.
Related Papers:
Quiksilver Case Study
Quiksilver, Inc. Case Study
Brief Company Description
Founded in 1976, Quiksilver, Inc. (hereinafter alternatively "the company") is headquartered Huntington Beach, California and competes in the global surf- and sports-apparel and… read more
Case Study 10 pages (2910 words) Sources: 2 Topic: Business / Corporations / E-commerce
Humanistic Theory in, Julie Case Study
Humanistic Theory
In case study, Julie is being affected by a host of different social problems that are helping contribute to her overall levels of anxiety. According to the humanistic… read more
Case Study 6 pages (2134 words) Sources: 1 Topic: Psychology / Behavior / Psychiatry
Comprehensive Original Ethical Situation Case Study
Business Ethics Case
The Examination of a Business Ethics Dilemma: A Case History of a Medical Supply Company
Introduction of Dilemma:
The functionality and long-term viability of an organization may… read more
Case Study 15 pages (4454 words) Sources: 3 Topic: Business / Corporations / E-commerce
Root Cause Analysis Essay
pain from a dislocated shoulder following an episode of passing out, patient Mr. B experiences a massive drop in blood pressure and oxygen saturation and eventually presents with no discernible… read more
Essay 3 pages (815 words) Sources: 3 Topic: Healthcare / Health / Obamacare
Performance Management Colbran Institute Case Study
Performance Management
An Overview and Analysis of Key Performance Management Practices and Their Application to a Case Study
Performance management can be specifically defined as "an ongoing process of communication… read more
Case Study 7 pages (1797 words) Sources: 10 Topic: Management / Organizations
Mon, Jul 1, 2024
If you don't see the paper you need, we will write it for you!
We can write a new, 100% unique paper!