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. Bs O2 saturation alarm is heard and shows low O2 saturation (currently showing a sat of 85%). The LPN enters Mr. Bs 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. Bs 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. Bs B/P reading is 58/30 and the O2 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 patients pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and upon the familys wishes the patient is transferred to a tertiary facility for advanced care.
Seven days later the receiving hospital informed the rural hospital that EEGs 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 hospitals 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 Js 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 patients outcome).
B. 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: