The primary focus when carrying out a Risk cause analysis is not to point fingers
and criticize individuals for their poor performance (McNutt & Hasler, 2006). The major
focus of RCA is the processes and the systems, not to find fault but to establish what
failed in order for a sentinel event to occur. In this sentinel event where Patient B is
admitted in a hospital after dislocating his shoulder but loses his life in the end there must
be a clarification to the event process, establishing the contributing factors that caused the
final outcome (Spath, 2007). Ultimately the hospital management will be in a position to
develop an action plan intended to enhance improvements so that such an event will
never recur again.
- Patient Observation Procedures
After patient B’s operation, nurse J leaves the room and there is no trained
personnel to watch over the patient despite the fact that he has undergone a major surgery
and he is still sedated. Later when patient B’s son comes in he is allowed to watch over
him. At 16:35 Mr. B’s blood pressure reading is 110/62 and his O2 saturation is 92%. His
ECG and respirations are not monitored; there is no trained person to note the fluctuating
trends in the medical progress of the patient (Wald, 2007).
- Medication Management
After the patient is examined by nurse J she is able to take note of his blood
pressure, and medical history including the numerous drugs he has been taking to
alleviate pain. When nurse J is done with the patient she hands him over to Doctor T the
emergency department physician. Doctor T is not keen to observe the history of the
4Running Head: RISK MANAGEMENT
patient, to begin with, patient B has been using narcotics and his weight 230 lbs. In his
attempt to relocate Mr. B’s left shoulder he instructs Nurse J to administer the patient 5
mg of Valium IVP. Unfortunately, the patient is not sedated and the doctor instructs
Nurse J to give the patient 2 mg of IV Dilaudid. After another five minutes, Dr. T is still
not satisfied with the level of sedation Mr. B has achieved and instructs the nurse to
administer another 2 mg of IV Dilaudid and an additional 5 mg of Valium. Instead of
using one type of medication to sedate the patient the physician uses both Valium IVP
and IV Dilaudid to achieve muscle relaxation from the Valium, to aid the relocation, and
to achieve pain control and sedation from the Dilaudid. Dr T. seems to fall short in
establishing the patient’s facts before selecting the right sedation medicine for him and he
also fails to offer the accurate dose ranges (Woodhouse Burney & Coste, 2004).
- Care planning
Although patient B has gone through a major operation he is not placed on any
supplemental oxygen (Spath, 2007). As nurse J examined him prior to the operation she
noted that the Circulation in the left extremity shows compromise with a capillary refill
time of six seconds. When the call comes through for that the paramedics are enroute
with a 75- year-old patient in acute respiratory distress Nurse J places Mr. B on a
dynamap to monitor his B/P every five minutes and leaves his room. Notably there is a
Respiratory Therapist in the hospital who should attend to the anticipated 75 year old
patient but nurse J leaves a patient after a critical operation with no one to attend to him.
- Competency Assessment
As patient B. blood pressure changes for the worse Nurse J as well as the LPN on
duty are discharging two patients and seeing to the patient who has just arrived.
5Running Head: RISK MANAGEMENT
Meanwhile, the ED lobby is filling up as additional patients are arriving. The O2
saturation alarm on Mr. B is alarming “low sat” and is currently showing a saturation of
85%. The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P
reading. Notice that the patient has a problem with the reducing oxygen saturation but the
LPN has not considered putting him under supplemental oxygen but only resets the B/P
alarm (Senders, 2004). At this point the practitioner should have noted the increasing
blood pressure and the gradually reducing oxygen saturation and taken the necessary
precautions to bur any losses but he is too pre occupied with other obligations.
- Communication among staff
There is poor information flow between the staff members attending to patient B.
For instance when the LPN noted that the increasing blood pressure and the low oxygen
saturation he did not even consult with Nurse J to understand the history of the patient.
He did not know that the patient had a compromise with a capillary refill time of six
seconds, thus he did not handle his situation with the caution required.
- Adequacy of technological support
In this hospital there appears to be a shortage of nurses to provide the necessary
labor force. For instance, once Nurse J completes working on patient B she gets fully
engaged with the respiratory distress patient. At 16:43 Mr. B’s son comes out of the room
and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the
B/P reading is 58/30 and the O2 saturation is 79%. The patient is not breathing, and no
palpable pulse can be detected. This happens because there has been a minimal number
of the support staff to watch over Patient B’s condition.
- Availability Of Information
6Running Head: RISK MANAGEMENT
Dr T. did not have information that patient B had been consuming narcotics and
that his weight was at 230 lbs as a result he was unable to administer inaccurate dose
ranges an aspect which could have possibly triggered the high blood pressure after the
- Communication with family
When Patient B’s son came to attend to him the practitioners did not communicate to
him on how to read alarming signs in his conditions. Finally when it was too late the son
ran to seek for help after the alarm went off. After this episode the code team strives to
restore the patient to his normal state, in the end the patient is not breathing on his own
and is fully vent dependent. The patient’s pupils are fixed and dilated. He has no
spontaneous movements and does not respond to noxious stimuli. Air transport is called;
upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.
- Security Systems And Processes
Notably, there is no fixed procedure on the processes that should be undertaken after
operating on an individual. Even though there are many nurses and physicians in the
hospital all the work seems to be heaved on nurse J and this compromise on the quality of
the service delivered to the patient. Moreover, there is no specific practitioner assigned to
patient B irrespective of his complex health situation (McNutt & Hasler, 2006). In the
end his body is overwhelmed by low 02 concentrations and high blood pressure.
7Running Head: RISK MANAGEMENT
McNutt R, Abrams R, Hasler S (2006).Determining medical error: three case reports. Eff
Clin Pract. 2006;5:23-8.
Senders JW.(2004). FMEA and RCA: the mantras of modern risk management. Qual Saf
Health Care. 2004; 13:249-50.
Spath PL (2007) Investigating Sentinel Events: How to Find and Resolve Root Causes.
Forest Grove, OR: Brown Spath and Associates.
Wald H, Shojania KG (2007) Root cause analysis. In: Shojania KG, McDonald KM,
Wachter RM, eds. Making Health Care Safer: A Critical Analysis of Patient
Safety Practices. Evidence Report/Technology Assessment No. 43, AHRQ
Publication No. 01-E058; July 2007.
Woodhouse S, Burney B, Coste K (2004). To err is human: improving patient safety
through failure mode and effect analysis. Clin leadersh Manag Rev. 2004;18:32-