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 in the scenario attached 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.
It is 3:30 p.m. 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, and 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, â€œMy hip area and leg hurt really bad. I have never had anything like this before.â€ Patient rates
pain at 10 out of 10 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. Bâ€™s
leg is stabilized and then is further evaluated and discharged from triage to the emergency department (ED)
patient room. He is admitted by Nurse J. Nurse J finds that Mr. B has a history of impaired glucose tolerance
and prostate cancer. At Mr. Bâ€™s last visit with his primary care physician, laboratory data revealed elevated
cholesterol and lipids. Mr. Bâ€™s current medications are atorvastatin and oxycodone for chronic back pain.
After Mr. Bâ€™s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission findings, and Dr.
T proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency
department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. Bâ€™s arrival,
6Ã˜23Ã˜2019â€ WGUâ€ Performanceâ€ Assessment
the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing
headache. The patient rates current pain at 4 out of 10 on numerical verbal pain scale. The patient states that
she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second
patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for
this patient. Both of these patients were examined, evaluated, and cared for by Dr. T and are awaiting further
treatment or orders.
After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The
medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had
no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication
hydromorphone is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of
sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an
additional 5 mg of diazepam IVP. The physicianâ€™s goal is for the patient to achieve skeletal muscle relaxation
from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. Bâ€™s hip. The
hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patientâ€™s
medical history, Dr. T notes that the patientâ€™s weight and current regular use of oxycodone appear to be
making it more difficult to sedate Mr. B.
Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place.
The patient appears to have tolerated the procedure and remains sedated. He is not currently on any
supplemental oxygen. The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of
discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency
department that the emergency rescue unit paramedics are enroute with a 75-year-old patient in acute
respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor
his B/P every five minutes and a pulse oximeter. At this time, Nurse J leaves Mr. Bâ€™s room. The nurse allows
Mr. Bâ€™s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. Bâ€™s B/P is
110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and respirations
are not monitored.
**** PLEASE SEE ATTACHED*** INCLUDES REQUIRED PAPERS AND QUESTION ****