Western Governors University Rrt1 Task 2

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Wesley Hunter 000450445 RTT1 task 2 This sad scenario is an example of when well-meaning people try to do too much and in doing so forgo their clinical judgement, training, and the hospital policies designed to keep them and the patients safe. This paper will attempt to analyze the sentinel event of Mr. B, a sixty seven year old man with left leg pain and deformity presenting to the emergency department. A root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome) will be presented. A process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario will be discussed. Change theory will be utilized to implement the plan. A failure mode and effects analysis (FMEA) will project the likelihood that the process improvement plan suggested will not fail. Additionally the role of the professional nurse in functioning as a leader in promoting quality care and influencing quality improvement activities will be discussed. A.Root Cause Analysis A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). The people involved in the RCA should be the people involved in the scenario: the RN (Nurse J), the LPN, the physician (Dr. T.), the emergency room manager, and a figure from administration (Chief Nursing Officer?). These participants should conduct a RCA to determine the causative factors that lead to Mr. B’s sentinel event. The first step would be to gather data about the situation. Mr. B’s presentation, vitals, health history, lab values, pain score, medications he already takes, and medications he received (amount, dose, and times) during the conscious

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