blacked out while showering

Introduction:

It is 15:30 on a Thursday when Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a 50-bed rural hospital. He has been brought to the ED by his son and is complaining of a dislocated left shoulder after falling in the shower. He states that he “just blacked out” while showering, and when he came to after the fall, his shoulder hurt very badly and appeared disfigured.

Mr. B’s vital signs on arrival were B/P 140/96, HR-97 (regular), T-98.8, R-22 and his weight was 230 lbs. Mr. B has no known allergies. He appears to be in moderate distress from the pain. Circulation in the left extremity shows compromise with a capillary refill time of six seconds. The patient is taken into the trauma room where Nurse J begins taking Mr. B’s assessment and history. She finds that Mr. B has a history of hypertension, an old back injury, gastric reflux, and depression. He was found to have elevated cholesterol and lipids at his last visit with his primary care physician. He is currently taking HCTZ, Tenormin, Prilosec, Crestor, Cymbalta, and Lortab prn for pain. After the nurse completes the assessment, she informs the ED physician of the patient, and the physician then proceeds to examine Mr. B.

Staffing on this day consists of one RN, one LPN, one secretary, and one ED physician. Respiratory Therapy is in house and available as needed. The ED only has two other patients at the time of Mr. B’s arrival. One patient is a 43-year-old female complaining of a sore throat. A rapid strep test is pending. This patient is stable. The other patient is a stable eight-month-old with nasal congestion and a low-grade fever. Labs and a chest X-ray are pending on this patient. Both of these patients have been examined by the physician and are waiting for further treatment or orders.

After Dr. T, the emergency department physician, examines Mr. B, he decides that he will use moderate sedation on the patient and attempt to relocate Mr. B’s left shoulder. Dr. T instructs Nurse J to administer the patient 5 mg of Valium IVP. The Valium is given at 16:05. After five minutes, the Valium appears to have had no effect on the patient. Dr. T instructs Nurse J to give the patient 2 mg of IV Dilaudid. The Dilaudid is given IVP at 16:15. After another five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs the nurse to administer another 2 mg of IV Dilaudid and an additional 5 mg of Valium. The physician’s goal is for the patient to achieve muscle relaxation from the Valium, which will aid the relocation, and to achieve pain control and sedation from the Dilaudid. The doctor notes that the patient’s weight and current use of narcotics on a regular basis appear to be making it more difficult to sedate Mr. B.

Finally at 16:25 the patient appears to be sedated and the successful reduction of his shoulder 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 16:30. At this time, a call comes over the radio that the paramedics are en route with a 75- year-old patient in acute respiratory distress. Nurse J places Mr. B on a dynamap to monitor his B/P every five minutes and leaves his room. She allows Mr. B’s son to come back and sit with him. At 16:35 Mr. B’s blood pressure reading is 110/62 and his O2 saturation is 92%. ECG and respirations are not monitored.

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Nurse J as well as the LPN on duty are discharging the other two patients and seeing to the patient who has just arrived. Meanwhile, the ED lobby is filling up as additional patients are arriving. The O2 saturation alarm on Mr. B is alarming “low sat” and is currently showing a saturation of 85%. The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P reading.

Nurse J is now fully engaged with the respiratory distress patient—ordering respiratory treatments, CXR, labs, etc.

At 16:43 Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the B/P reading is 58/30 and the O2 saturation is 79%. The patient is not breathing, and no palpable pulse can be detected.

A code is called immediately, and the son is escorted to the waiting room. The Code Team arrives and begins resuscitative efforts. When connected to the monitor, Mr. B is in V-Fib. CPR begins immediately and Mr. B is intubated. He is defibrillated; reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully vent dependent. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called; upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.

Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and he subsequently died.

The hospital where Mr. B. was originally seen and treated had a moderate sedation policy that had the following monitoring requirements: patient is to remain on continuous B/P, ECG, pulse oximetry throughout the procedure and until the patient meets discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (back-up) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. She had current ACLS certification and was an experienced critical care nurse. Her prior annual clinical evaluations by her manager demonstrated that she was “meeting requirements.” She did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.

Task 2:
D. Complete a root cause analysis (suggested length of 2–3 pages) that takes into consideration at least nine causative factors that led to the sentinel event and this patient’s outcome

E. Organize your analysis with the causative factor having the greatest impact first and others in order of descending importance.

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