RTT Task 2 The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore…
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Root Cause Analysis It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs death. The questions that follow are pertinent because they set up a scenario with valid questions that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the future. In the case study, it appears that a lack of protocols as well as a lack of communication amongst staff members may have been contributing factors which led to death of…
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RTT1 Task 2 Organizational Systems and Quality Leadership Western Governors University Leslie Baylor A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome). “A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The prevention of errors is the main emphasis of a RCA…
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patient several times throughout the shift. Nurses have the greatest opportunity to provide noticeable quality of care to a patient. Using the best evidence-based nursing intervention can directly improve patient outcomes. For example, a good bedside nurse will turn a bedridden patient so that patient does not develop pressure ulcers. Since nurses are at the forefront of patient care, they should be highly involved in quality improvement activities at their workplace. For example, a professional…
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Professional Development Assignment Michelle Turner Aspen University Theoretical Foundations N507 Heidi Haldeman December 6, 2014 Professional Development Assignment When learning that the next course on my syllabus was Theoretical Basis for Nursing my reaction was just as described in the preface of the assigned textbook “ugh!”. For starters I had no idea how I could apply this to my day to day. Also as I skimmed the content I saw the word research way to many times. But, as I have spent time…
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leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam * Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation * Dr. T orders additional sedation medication * 2mg of Hydromorphone…
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These types of things causes lawsuits against the medical practice and the providers involved. When working in the medical field, it is best that you comprehend these elements, so that you can always perform at your best. Patients will receive the best care, when they have medical team members, who always have their patient’s best interest at heart. Displaying professionalism and ethics, is good for the company as well as the patients that are being serviced. Doctor and patient relationships are also…
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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…
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Governor's University RAFT Task 2 A.1 Sentinel Event A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). Root Cause Analysis: Potential Child Abduction Recently a three year old female was brought to Nightingale Hospital for an outpatient surgical procedure accompanied by her mother. They presented to the registrar who entered all information into the computer and copied…
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Evidence-Based Practice and Applied Nursing Research Yvette Riviere Western Governor’s University Evidence-Based Practice and Applied Nursing Research Article critique Sayre, M.M., McNeese-Smith, D., Leach, L.S., & Phillips, L.R. (2012). An educational intervention to increase “speaking-up” behaviors in nurses and improve patient safety. Journal of Nursing Care Quality, 27(2), 154-160. AREA|METHOD OF REPORT (HOW IT WAS ADDRESSED)| 1. Background information2. Review…
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