In the case study presented, a sixty-seven year old male patient goes into cardiac arrest (“codes”) after being administered a sedative without proper monitoring. This event could clearly have been prevented. As such, a root cause analysis is required to determine what decisions and actions led to the sentinel event. This paper will offer a root cause analysis of the event. It will also consider possible ways to change incidents such as this before they occur.
The root cause analysis identifies several critical errors in the care of this patient. The emergency department (ED) nurse is most certainly busy. She is currently working on discharging a patient, administering care to this patient and dealing with a possible pediatric appendicitis. She is assisted by an LPN. Furthermore, the paramedics bring a patient in severe respiratory distress during this time as well. This situation created the ideal opportunity for a patient not to be monitored adequately.
The critical errors noted include:
1. The patient is given both diazepam and hydromorphone in rapid succession; the doctor did not wait enough time to determine the effect of the valium. The doctor was hasty in ordering an additional sedative.
2. The nurse was also hasty in assuming that the patient was stable; these drugs stay in the system for a significant amount of time and may result in sedative effects for hours in an elderly patient. The patient should have been attended.
3. The patient was not placed on oxygen. These drugs are known to cause respiratory depression. The patient began to show signs of respiratory depression when his oxygen saturation was 92%. However, the LPN did not recognize this.
4. The patient was not placed on full monitoring, include an ECG. This is required protocol for a patient who is sedated.
5. The ED was understaffed with only one LPN and one RN. Furthermore, it was quite busy at the time, which led to many distractions.
6. Respiratory therapy should have been called to the ED to assist in monitoring the patient.
Change theory can be used to help determine the appropriate changes that should be made to prevent another occurrence such as this. First, we need to unfreeze the forces behind this event. This includes rejecting the idea that when we use conscious sedation that it will all take effect immediately. We also must reject all assumptions and follow safety protocols that are set in place. Additional changes must including relying on training, insisting on better staffing and calling the people who are on call to assist with influx of patients in the ED.
Second, we must adopt standards associated with procedures, such as monitoring of patients who are sedated. In the training, we must be sure that there is a forced prompt when that much sedative is administered in that timeframe; this would lead the nurse to associate that amount of sedative with moderate sedation and lead her through a series of monitoring prompts. This includes alerting her to engage in the steps needed for safe moderate sedation. Dispensing machines and computerized reports may offer the opportunity for prompts, such as requiring the nurse to document the use of ECG and oxygen administration.
Next, we need to move toward changing to a more liberating thought process in the ED and encourage staff to voice their ideas as to how to avoid this happening in the future. Adopting a safe environment for staff to voice concerns and ideas will help break away for destructive patterns of taking on too much and finding themselves drowning in regrets. Put the focus on supportive measures to nurture a safer ED. In addition, the process should not focus on blame, but rather on improving the outcomes for the patients.
The next step is conducting a failure mode and effects analysis (FMEA). The members of the team will include ED physicians and nurses, administrators, respiratory therapists and a patient advocate. The interventions will be tested in a diverse scenario that will include a similar number of patients of similar acuity. The pre-steps for this process include asking all individuals to thoroughly document the events as they recall them. It also includes reviewing all protocols that are currently in place.
The three steps of a FMEA are severity, occurrence and detection. The severity of this incidence is obvious. The rating for severity is from Level I to Level VI. This is a Level V severity, as it resulted in a death. Level VI is considered catastrophic and results in multiple deaths. Occurrence refers to the likelihood that this would happen again. The probability of a recurrence, if all safety measures are followed is remote. Tragically, humans often do not follow safety measures and there is still a possibility that this would occur again. The detection is considered almost certain. In a health care setting, it is not possible to not detect a cardiac arrest. However, it would be possible to not detect that the code was a result of the same issue.
Nurses are absolutely critical in ensuring that this safety program is enacted and carried out. Obviously, it is up to a nurse to indicate that he or she is not capable of providing the necessary level of care for a patient due to any number of reasons. Furthermore, it is up to the nurse to ensure that proper monitoring is done. The nurse should also question any orders from a physician that might place the patient in harm’s way. This includes the too rapid administration of a number of sedatives, such as occurred in this situation. The nurse should have recognized the danger associated with the orders.
This case presented a tragic situation in which a patient experienced cardiac arrest as a result of a number of issues. These issues included poor monitoring, heavy workload and improper orders. It also reflected that safety programs were not followed to ensure that the sentinel event did not occur. As such, a root cause analysis is required to determine what led to the events, and most importantly, how to prevent future similar occurrences. After a root cause analysis, it is also required to conduct a failure mode and effects analysis. This programs are also designed to prevent a future occurrence, by recognizing the severity of the hazard.
