Mr B Root Cause

Opioid use in the US has increased over the years, and this has led to an increase in substance abuse. Substance abuse is not only associated with use of illicit drugs but also prescription drugs. In 2015, of the 20.5 million reported cases of substance abuse, 2 million had an abuse disorder related to prescription pain relievers and 591,000 associated with heroin.1 The increase in substance abuse disorder has led to an increase in opioid related death. In 2015 drug overdose was the leading cause of accidental death in the US with 52, 404 lethal drug overdoses.2

"The toxicology studies on blood reveal the presence alprazolam, and amphetamine at levels likely consistent with the therapeutic range, a metabolite of buproprion and a high level of fentanyl. Phenylpropranolamine and amphetamine are present in the urine. When fentanyl and alprazolam are taken together there may be a synergistic central nervous system depressive effect. Based on the history and circumstances, s currently known, the manner of death is accident."

The patient did not receive standard treatment to prevent the formation of a DVT. What are some possible reasons why this error occurred? The first reason was that the nurses and staff on the floor were so focused on his admitting problem being related to COPD, which caused his respiratory infection, which then caused his kidneys to not function properly. Since his kidneys were not up to par, the staff wanted to make sure that he was not going to go into kidney failure, so that was their number one priority at the time. Secondly, the admitting doctor did not order DVT (deep vein thrombosis) prophylaxis. Based on his thrombosis risk factor assessment, the patient would have scored as a high risk. He should have been placed on sequential compression devices (SCD), and either heparin or lovenox (University of Michigan Health System, n.d.). The most alarming reason was that the nurse did not

Opioid drugs are some of the most widespread pain medications that we have in this country; indeed, the fact is that opioid analgesic prescriptions have increased by over 300% from 1999 to 2010 (Mitch 989). Consequently, the number of deaths from overdose increased from 4000 to 16,600 a year in the same time frame (Mitch 989). This fact becomes even more frightening when you think about today; the annual number of fatal drug overdoses in the Unites States now surpasses that of motor vehicle deaths (Alexander 1865). Even worse, overdose deaths caused by opioids specifically exceed those attributed to both cocaine and heroin combined (Alexander 1865).

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

Lack of situation awareness by the nurse and failure to use the SBAR protocol when on the phone to the cardiologists.

Several errors and hazards can be identified as possible factors leading to the sentinel event. The ER appeared to be terribly understaffed that day with only one ER physician, one RN, one LPN, and a secretary.

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

First of all, in order to improve patient safety, staffing levels need to be appropriate. In this case, as the patient load increased, the staffing level did not. There was only one RN and on LPN on duty. As a proponent of acuity based staffing, I would have a system in place that allowed for staff to be assigned based on a patient acuity scoring system that would be implemented, that would staff the unit not only based on the number of patients but also for the care required. In this case we have a patient that requires constant monitoring, as well as another emergent respiratory distress patient. Had another nurse been assigned to the unit, Nurse J, who was trained in conscious sedation, would have been able to adhere to the existing policy and provide constant monitoring of Mr. B which most likely would have avoided the outcome presented in this scenario.

As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.

Nursing-sensitive indicators are utilized in healthcare to increase quality patient care, as well as patient safety. They reflect the organization, procedure, and products of patient care. In the presented scenario involving Mr. J, nursing-sensitive indicators can be used to identify the issues that interrupted the flow of quality patient care.

Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.

For statistical purposes, prescription harm will be solely measured by the prescription overdose deaths in my study. The other types of prescription harm discussed, including extensive drug effects and drug-related emergency department visits, are either estimated values or moderately controversial on the source of the harm. Additionally, statistical evidence and conclusions made based on overall prescription data would hold little validity due to many extraneous factors that differ from one medication to the next; therefore, I will focus exclusively on opioid analgesics, a common prescription for chronic pain relief.

The U.S. Department of Health and Human Services (HHS) (2013) reported that U.S. prescription drugs, especially opioids analgesics, have been increasingly involved in drug overdose deaths. Unfortunately, drug overdose deaths from prescription drugs, especially opioids analgesics outnumbered deaths related to motor vehicle accidents back in 2009. Actually, in 2010 only, 16,651 deaths were connected to opioids overdose, an increase of 60 percent of overdose losses from any other drug class, prescribed or illegal. Specifically, in Florida, the attorney general of Florida (2012) stated that an average of seven Floridians die every day as a result of overdose from prescription drugs, which is five times greater than losses from the use of all illegal drugs put together.

Pulmonary Embolism is a life-threatening condition that has most serious manifestation of venous thromboembolism that is leading cause of sudden death. “With massive pulmonary embolism (PE) being the first or second leading cause of unexpected death in adults, protection against PE is critical in appropriately selected patients” (Georgiou, Katz, Ganson, Eng, & Hon, 2015). How does this effect the nursing? If Pulmonary embolism is suspected, nurses goal is to halt PE that is forming a clot and from embolizing. Nurses must be extra diligent in preventing Pulmonary embolism, be able to recognize it early, provide prompt help and start appropriate treatment because if it is unrecognized or untreated it can cause death very quickly. Knowing how to intervene when PE is suspected can make a difference in life a threatening emergency. “Massive PE, defined as causing 50% or more occlusion of the pulmonary capillary bed, can result in obstructive shock with systemic hypoperfusion (low cardiac output and acute pulmonary hypertension with right ventricular failure). ANA’’.