Nursing Root Cause Analysis
Follow Task instructions: please review enclosed scenario and have detailed explanations for topics (A- C4) . Joint Commission is a useful website. Reference and title page must be included however an Abstract isnt necessary. Paper must be a minimum of 10 double spaced pages not including reference. 4 pages total
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7 ask # .9-
Competencies: 734.3.1: Principles of Leadership The graduate applies
principles of leadership to promote high-quality healthcare in a variety of settings
through the application of sound leadership principles.
734.3.2: Interdisciplinary Collaboration The graduate applies theoretical
principles necessary for effective participation in an interdisciplinary team.
734.3.3: Quality and Patient Safety The graduate applies quality improvement
processes intended to achieve optimal healthcare outcomes contributing to and
supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance The graduate analyzes financial
implications related to healthcare delivery reimbursement access and national
initiatives
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:
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. B. 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. Bs 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. Bs last visit with his
primary care physician laboratory data revealed elevated cholesterol and lipids. Mr.
Bs current medications are atorvastatin and oxycodone for chronic back pain. After
the nurse completes Mr. Bs assessment Nurse J informs the ED physician of
admission findings and the ED physician proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN) one secretary and
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TUK#
2-
Competencies: 7343.7: Principles of Leadership The graduate applies
principles of leadership to promote high-quality healthcare in a variety of settings
through the application of sound leadership principles
734.3.2: Interdisciplinary Collaboration The graduate applies theoretical
principles necessary for effective participation in an interdisciplinary team.
734.33: Quality and Patient Safety The graduate applies quality improvement
processes intended to achieve optimal healthcare outcomes contributing to and
supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance The graduate analyzes financial
implications related to healthcare delivery reimbursement access and national
initiatives
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:
Scenario:
-+
It is 3:30 p.m. on a Thursday and Mr. B a 67-year-old patient arrives at the sixroom 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 BlP tz1l91 HR-88
(regular) T-98.6 R-32 and his weight was recorded at 175 pounds. Mr. B. 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. Bs 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 l. The admitting nurse finds that Mr B has a history
of impaired glucose tolerance and prostate cancer. At Mr. Bs last visit with his
primary care physician laboratory data revealed elevated cholesterol and lipids. Mr.
Bs current medications are atorvastatin and oxycodone for chronic back pain. After
the nurse completes Mr. Bs assessment Nurse J informs the ED physician of
admission findings and the ED physician proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN) one secretary and
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