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.
SCENARIO
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 R32, 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 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. B’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. B’s last visit with his primary care physician, laboratory data revealed elevated
cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After
Mr. B’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. B’s arrival,
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 physician’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. B’s hip. The
hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s
medical history, Dr. T notes that the patient’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. B’s room. The nurse allows Mr.
B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. B’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.
Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of
discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming
patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a
saturation of 85%). The LPN enters Mr. B’s room briefly, resets the alarm, and repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes
assessments, evaluation, and the ordering of respiratory treatments, CXR, labs, etc.
At 4:43 p.m., 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 blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2
saturation is 79%. The patient is not breathing and no palpable pulse can be detected.
A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins
resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR
begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and
vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm
with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the
ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond
to noxious stimuli. Air transport is called, and upon the family’s wishes, the patient is transferred to a tertiary
facility for advanced care.
Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in
Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had a moderate
sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG,
and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully
awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully
complete the hospital’s moderate sedation training module. The training module includes drug selection as well
as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had
completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced
critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was
“meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was
available and in working order in the ED on this day.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no
more than a 10% match to any one individual source can be directly quoted or closely paraphrased from
sources, even if cited correctly. An originality report is provided when you submit your task that can be used as
a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will
be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect.
The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Explain the general purpose of conducting a root cause analysis (RCA).
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
A2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the
sentinel event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario
outcome.
B1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the
proposed improvement plan.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
C1. Describe the steps of the FMEA process as defined by IHI.
C2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and
detection to the process improvement plan proposed in part B.
Note: You are not expected to carry out the full FMEA.
D. Explain how you would test the interventions from the process improvement plan from part B to improve
care.
E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care
• improving patient outcomes
• influencing quality improvement activities