T is not satisfied with Mr.. Bi’s level of sedation and orders an additional dose of OMG hydrophone and OMG disappear PIP. At errors-Mr.. B is sedated and a successful reduction of his left hip takes lace. The patient’s son is at the bedside. 3 At errors-post-procedural VS.. BP 1 1 0/62 and 02 sat 92%, pot. Is on RA. At the same time, the ERE has become congested with new incoming patients, and receives an emergency rescue call Norte to the facility. The ERE staff is overwhelmed with the emergency care of a patient in respiratory distress, and training the influx of new patients. Mr..
BBS 02 sat alarms, indicating an 02 sat of 85%; the patient is on RA, and the L VAN silences the alarm, recycles the BP and leaves the room. (Without assessing the patient. ) At errors-The low 02 sat alarm keeps going off, and now the pot. S son leaves the room, and informs the nurse that the monitor is alarming. The RAN enters the room; BP 58/30 and 02 sat 79%. The patient is not breathing and no palpable pulse can be detected. A code blue is called, the RAN starts CPRM, and the patient is attached to the heart monitor, which shows IF. CALLS is being performed. At 171 errs- After 30 minutes Of CAL_S the EGG converts to a NSA. BP 110/70.
Pot. Is unresponsive, pupils are fixed and dilated, and patient is initiated and placed on a ventilator. Sentinel Event Seven days later Mr.. B has an EGG done that confirms brain death, life purport was removed, and Mr.. B subsequently dies. Root Cause Analysis (RCA) findings: Major deviations occurred during the course of Mr.. Bi’s emergency room visit. Failure to comply with hospital policies and procedures regarding conscious sedation, lack of knowledge regarding medication administration, and inadequate staffing ratios, 4 Error and hazards that were contributing causative factors, by the individual health care team members.
Mr.. B wasn’t placed on a continuous B/P, EGG and pulse geometer during the procedure. Mr.. B post-procedure VS.. Sedated, 02 sat 92% on RA; RAN didn’t provide any placement 02 for an 02 sat of and no record of the OR or HER. The patient didn’t meet the specific discharge criteria: fully awake, VS.. Nor was he recovered properly. RAN;recently completed the module for conscious sedation, but didn’t question the Mad’s orders regarding the protocol. LAP- silences the patient’s 02 saturation alarm of 85%, and didn’t notify the RAN or MD of the decrease in 02 saturation.
DEED MD-didn’t consider the patients age, and chronic use of pain medications. Error and hazards which were contributing causative factors, by the facility ; The DEED staff was overwhelmed, with the rapid onset of new ERE admissions, additional ERE staff was not called to come in, nor was the nursing supervisor notified of the changes. The facility should have been placed on divergence, until the back-up staff reported to work. Breakdown of communication amongst the DEED MD and RAN, they had resources but didn’t utilize them.
Recommended Corrective Action Plan and FAME 5 Individual Health Care members: Implementation of stricter protocols regarding conscious sedation: Effective immediately, procedural guidelines will be conducted per protocol. Recommendations: Respiratory Therapist will be present during procedure, until patient meets discharge criteria. Within 10 days the conscious sedation protocol will be reviewed and evaluated by the committee, to ensure safe and best practices are being implemented. Within 30 days of this report, all staff including Urn’s, Lava’s and Meds will be educated on the facility’s conscious protocols.
Updates and reviews of conscious sedation protocols will be reviewed by DEED staff, every 90 days, and then every months. Annual educational update will include: conscious sedation protocol, medication administration, and knowledge of the mechanism of action. For example in drugs there is: onset of action, peak, duration and attention side effects, and assessment of altered scoring, prior to discharge. Facility Factors: Identifying protocols for safe staffing ratios: Effective immediately, the nursing supervisor will be notified of any emergency rescue transport to the facility.
Within 10 days of this report, safe nursing to patient ratios will be implemented. Within 30 days policy and procedure draft will outline patient acuity levels and staff ratios. Divergence protocols implemented which assist in the determination of when to place ERE on divergence. An understaffed department affects the capabilities of the emergency room to deliver safe and effective patient care. Failure Mode and Effects analysis (FAME): Multi-disciplinary team has been identified at the beginning of this report and will continue until the FAME is satisfied.
Pre-Steps include: 6 Identification of the failure mode: The primary cause of failure in this scenario is the failure of the healthcare team members to follow the conscious sedation protocol: This report will focus on education of all staff members. Data Collection: The team will gather and evaluate all internal and external data, scope of practice and clinical practice guidelines as outlined by the Board of Registered Nursing. All current hospital policies and procedures as it relates to conscious sedation.
Observation and Testing of conscious sedation modules: Conscious sedation protocols will be tested on a quarterly basis, which will include a skills test of medication administration, onset and duration of medication, assessment and evaluation using the Altered scoring protocol. A score of 99% pass will be required, if unable to meet this scoring guideline, then further education at the time is required. Failure Modes and Effects analysis (FAME) Is a systematic three-step knowledge process based on the Department of Defense Patient Safety Center (2004). These processes are: Severity, Occurrence and Detection.
The formula is The Risk Priority Number, or RPR, is a numeric assessment of risk assigned to a process, or steps in a process, as part of Failure Modes and Effects Analysis (FAME). The team assigns each failure mode a numerical value from 1 to 10. This numerical grading quantifies a likelihood that the failure will occur, likelihood that the 7 failure will not be detected, and the amount of harm or damage the failure mode may cause to a person. (Institute for Healthcare Improvement 2004. ) Goals The goal of this process is to decrease the RPR for a given high-risk process by 50 percent within 1 year.