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    Devry University
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Category > Computer Science Posted 16 Aug 2017 My Price 10.00

Rewrite this assignment in your own words, Writing Assignment Homework Help

Rewrite this assignment in your own words

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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Organizational Systems and Quality Leadership
Task 2
Sharon Wiggins
Western Governors University
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A. The sentinel event was related to respiratory arrest secondary to conscious sedation
procedure. There were several factors that played a role which included high patient census,
poor staffing, alarms dismissed by staff members, patient was left unmonitored, and no
supplemental oxygen initated prior to the procedure. When the patient was pulseless no CPR
was initiated until the code team arrived and critical interventions were delayed by the
emergency room staff. The patients medication reconciliation or history weren’t reviewed by the
emergency room physician. Tripple doses of intravenous valium and dilaudid were given
without a lapse in time. The patient was elderly and on chronic oral opioid medications.
“Normally these types of medications are administered with low doses and titrated per patient’s
sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event
is known as a sentinel event. In any situation that causes injury, or death a root cause analysis
must be completed and reported to the Joint Commission.
B. To implement a change in the conscious sedation procedure a team or committee needs to
be established. All staff in the emergency room can become active participants by joining a
committee or subcommittee. These main categories may include patient characteristics, task
factors, individual staff members, team factors, work environment, and organizational
management (IHI, 2014). A cause and effect, or wishbone graph can be constructed to clarify
the error and process for the team, leading up to the event. The committee then needs to develop
causal statements. These statements link the cause to its effects and then back to the main event
that promoted the root cause analysis. These statements link the cause to its effects and then
back to the main event that promoted the root cause analysis (Huber & Ogrinc, 2014). Guidelines
for writing causal statements include the need for clarity in the relationship, statements should
use neutral language and not imply blame, cause should be given for any human error, and any
violation of procedure should also have a preceding cause (Huber & Ogrinc, 2014).
Recommendations should meet the following criteria; they should be clearly linked to the
identified root causes, address all of the root causes, designed to reduce the likelihood of
reoccurrence, severity, be clear and concise (Huber & Ogrinc, 2014). A report is an important
part of the process that should be forwarded to management. The report should include the
committee’s progress, encourage each committe member to take an active role in the process and
may point areas in the plan are weak. The areas that are weak can be improved upon and when a
goal is reached (Huber & Ogrinc, 2014). Once the committee has come up with a solution to a
issue that is noted the report is forwarded to the chief executive officer. For the process of
change to be effective, it’s important for the committee to have staff and patient advocates that
represent each unit that might be affected by the change. When looking at making changes the
direct and contributory changes will help with process. In regards to Mr. B the direct causes
were alarms being ignored, pt not monitored appropriately which should have included blood
pressure, oxygen saturation, cardiac monitoring and patients level of sedation. No oxygen or
Etco2 monitoring either. High doses of intravenous dilaudid and valium without a lapse in time
according to standard aministration dosages per pharmacy. Side effects related to valium and
dilaudid intravenously include respiratory depression, cardiac arrythmia’s and hypotension.
Delay of life saving interventions by the emergency room staff. Contributory factors included
high patient census, poor staffiing, poor communication between staff and physician, patient on
chronic opioid medications, patient elderly and the emergency room conscious sedation protocol
wasn’t followed. To implement change there are several steps in the improvement process. One

 

 

Answers

CourseLover
(12)
Status NEW Posted 16 Aug 2017 01:08 PM My Price 10.00

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