Emboli Case Study
The root cause analysis has exposed multiple issues, not noticeable at first glance of the scenario. The physician’s sedation method was not per standard. During the recovering phase of the patient the monitoring process was not followed as per protocol, there is no reported data regarding sedation level assessments. The LPN who is not qualified to monitor a post sedated patient responded to a medical monitor alarm which is not in the scope of practice of an LPN. If Nurse J. had time and initially responded to the first alarms, she could have performed needed assessment such as neurological assessment and sedation assessment, the scenario might have had a different ending. Nurse J. would have found Mr. B.’s sedation level out of normal range and rescue measures could have been initiated sooner, using reversal agents, and cardiac failure might have be
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One outlier in this scenario that could have been addressed is the bruising and swelling of Mr. B.’s calf. In the event it was determined before-hand it was indeed a deep vein thrombus, it could have become dislodged during the hip manipulation procedure, causing a large emboli. The emboli, or blood clot, could have moved and blocked blood flow to the heart, which could cause a medical emergency in itself. If the family request an autopsy this report can provide clarification, it a blood clot or emboli indeed existed and if it was a determining factor in the terrible outcome of this scenario. Not knowing this information it will not be used in regard to root cause analysis in this paper, due to this might be a complete hypothesis. Inadequate staffing is the highest order root cause for this unfortunate event. The four identified root cause analysis in this paper are in order inadequate staffing, sedation protocol, post sedation monitoring, and LPN monitoring post
One outlier in this scenario that could have been addressed is the bruising and swelling of Mr. B.’s calf. In the event it was determined before-hand it was indeed a deep vein thrombus, it could have become dislodged during the hip manipulation procedure, causing a large emboli. The emboli, or blood clot, could have moved and blocked blood flow to the heart, which could cause a medical emergency in itself. If the family request an autopsy this report can provide clarification, it a blood clot or emboli indeed existed and if it was a determining factor in the terrible outcome of this scenario. Not knowing this information it will not be used in regard to root cause analysis in this paper, due to this might be a complete hypothesis. Inadequate staffing is the highest order root cause for this unfortunate event. The four identified root cause analysis in this paper are in order inadequate staffing, sedation protocol, post sedation monitoring, and LPN monitoring post