734.3.1 : Principles of Leadership
The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings through the application of sound leadership
734.3.2 : Interdisciplinary Collaboration
The graduate applies theoretical principles necessary for effective participation in an interdisciplinary team.
734.3.3 : Quality and Patient Safety
The graduate applies quality improvement processes intended to achieve optimal healthcare outcomes, contributing to and supporting a culture of safety.
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, “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
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.
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A:ROOT CAUSE ANALYSIS
An explanation of the general purpose of conducting an RCA is not provided.
The explanation does not accurately describe the general purpose for conducting an RCA.
The explanation accurately describes the general purpose for conducting an RCA.
An explanation of 6 RCA steps is not provided.
The explanation does not accurately identify or does not logically describe one or more of the 6 steps used to conduct an RCA, as defined by IHI.
The explanation accurately identifies and logically describes each of the 6 steps used to conduct an RCA, as defined by IHI.
A2:CAUSATIVE AND CONTRIBUTING FACTORS
An application of the RCA process to the scenario is not provided.
The application of the RCA process to the scenario does not accurately describe causative or contributing factors that led to the sentinel event outcome, or
the application does not accurately differentiate between causative and contributing factors.
The application of the RCA process to the scenario accurately describes the causative and contributing factors that led to the sentinel event outcome.
A proposed process improvement plan is not provided.
The proposal does not outline a logical process improvement plan, or the proposal does not logically discuss how the proposed plan will decrease the
likelihood of a reoccurrence of the scenario outcome.
The proposal outlines a logical process improvement plan and logically discusses how the proposed plan will decrease the likelihood of a reoccurrence of
the scenario outcome.
A discussion of the application of Lewin’s change theory is not provided.