An analysis of the patient’s history indicates that the patient was on treatment prior to the unfortunate blackout and shoulder dislocation. Nurse J’s history on the patient shows the patient was previously on a treatment with hydrochlorothiazide, crestor, and lortab among other drugs (Becker, 2001). These facts should have been the greatest guide when selecting the diagnosis, failure to which there would have been a significant error and endangerment to the patient’s life. With this in mind the question the paper attempts to answer is, where exactly did Dr. T miscalculate the decision on the diagnosis to accord the patient? To answer the question, a root cause analysis of each decision has been considered as the following discussion outlines (Becker, 2001).
The greatest mistake that Dr. T made was ignoring the company’s policies which state that, “the person conducting a moderate sedation must have had undergone training” (Lynn & Curry, 2011, p.3). Though nurse J had been trained, the doctor did not even try to consult her and this led to his sequential errors. As a result the doctor did not appropriately conduct the diagnosis and this was core to the events that followed afterwards. According to Lynn and Curry (2011) the following are required during moderate sedation; capnography, heart monitor, oxygen, and pulse oximeter. However, the doctor did not put this factor into consideration. Without the tools, the doctor could neither measure the response to the sedation appropriately nor sense when the situation of the patient was worsening (Lynn & Curry, 2011).
The second big mistake that the doctor did was to administer excess drug into the patient. Lynn and Curry (2011) states that, “a patient goes to a deeper sedation level if excess drug is administered” (p.3). In this level, the patient will need to be helped to breath, and the blood pressure will also decrease significantly. Additionally, if the patient had heart related disease the situation would worsen further.
It is noted that following moderate sedation the blood pressure of the patient decreased significantly and his situation of the patient worsened a big deal. This may be due to arrogance of the doctor on previous history which would have enabled him to know the impact of moderate sedation to the patient (Becker, 2001). The resulting events may have been as a result of the drugs he used in moderate sedation. For example, if a doctor mistakenly administers dilaudid in place of morphine the result is a sequence of events that leads to death of the patient (Becker, 2001).
The third root cause was failure to provide the patient with supplement oxygen. Lynn and Curry (2011) states that, “a person undergoing the procedure will require to be aided in breathing” (p.3). The doctor did not put this into consideration and by the time the son calls their attention the patient had even ceased breathing. The fourth root cause of the death was negligence to monitor ECG. It is notable that by the time the patient ceased to breath, there was no any respiratory diagnosis that had been done. This was further worsened by failure to perform ECG checks. In this way the patient could not fail to succumb to relating impacts (Lynn & Curry, 2011).
The fifth root cause of the death was failure of the doctor to monitor the patient’s response to the treatment. Throughout the process, it is noted that the doctor was not involved in monitoring Mr. B’s response to the sedation at any time. As the doctor, he would have known the appropriate action to take as soon as an observation was noted. The absence of his intervention subsequently led to worsening of the case to a level that recovering of the patient was hard. The sixth cause was occupying nurse J with activities that would not enable her to have a close observation of this case that was more serious. This subjected the patient to further detriment. Actually, this case would have been best handled by nurse J who was trained in moderation sedation (Lynn & Curry, 2011).
The seventh root cause was the fact that the doctor ignored presence of the other staffs. It is notable that the facility had enough back up staff on the day of the accident (Lynn & Curry, 2011). It was a bigger neglect by the doctor to act in the way he presented himself and actually questions arise in regard to his practice qualifications. The eighth mistake was failure to involve the emergency department in the diagnosis of the patient. It is noted that the emergency department staff were busy taking of the details of the other patients that were arriving, thus making it hard for them to intervene in the treatment. The ninth root cause of the death of the Mr. B is leaving his son to care for him (Becker, 2001). Unless the patient is completely out of danger, the patient is not supposed to be left in the hands of a non-medical practitioner.
References
Becker, C. (2001). Root-cause trouble. Modern Healthcare, 31(25), 5.
Lynn, L.A., & Curry, J. P. (2011). Patterns of unexpected in-hospital deaths: a root cause analysis. Patient safety in surgery, 5(1), 3.