Nursing Task Case Solution And Analysis, HBR Case Study Solution & Analysis of Harvard Case Studies

Answer # 1
The RCA (root cause analysis) is one of the techniques which is for analyzing adverse events. The technique helps in understanding the factor that causes error and hazards whichcreate the sentinel event. Mr. B had been admitted to the hospital due to injury on his hip by tripping over and was in severe pain. For relieving his pain, he had been given ahigh amount of sedatives which are 10mg of diazepam and 4 mg of hydromorphone. The reason for administering ahigh amount of sedatives was mainly because of the patient’s regular use of oxycodone whichcaused difficulty for the sedatives to affect.
In respect to the root cause analysis, the overdose of sedatives that had been administered was one of the major error by the nurse and doctors. The physician and nurse had ignored the fact that the patient had been suffering from various diseases such as impaired glucose tolerance and prostate cancer.
The second root cause of the patient’s death was that after the patient was finally sedated Mr. B was in distress, he wasn’t given any supplemental oxygen nor were his respiration and ECG being monitored. This caused the patient to be exposed to the dangers of not breathing.
Nursing Task Harvard Case Solution & Analysis
Thirdly, the physician of the emergency room failed to identify that the patient was suffering from deep vein thrombosis in which a blood clot was formed on Mr. B’s leg. Lastly, the nurse and the physician which were assigned on treating Mr. B were tasked to watch over other patients as well. This caused less focus towards Mr. B and also the nurses and doctors were distracted due to thearrival of new patients in the emergency ward. Due to this, the licensed practical nurse just came in Mr. B’s room for a moment and reset the alarm when its O2 were low.
Answer # 2
The improvement plan that would lead to a decrease in the reoccurrence of the problems that had been caused by the nurses and physician on this scenario is by properly training them when it comes to sedating the patient. The nurse and physician overdosed the patient by administering ahigh amount of sedatives and ignoring the fact the patient was old and had several diseases. The steps for decreasing the reoccurrence of the scenario is by educating the nurses as how much sedatives they must give along withreviewing the patient’s medical history.
Another improvement plan would be to educate nurses on providing with the supplemental oxygen and also monitoring ECG and respirations of the patient who has even a minimal chance of the problem for breathing. Another step would be through assigning fewer patients to the nurses so they could provide quality care to the patient instead of neglecting patients which showfewer problems................

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