Pain From a Dislocated Shoulder

¶ … pain from a dislocated shoulder following an episode of passing out, patient Mr. B experiences a massive drop in blood pressure and oxygen saturation and eventually presents with no discernible pulse and is not breathing. Resuscitation efforts are eventually able to establish a normal sinus rhythm, but the patient is not breathing on his own; Mr. B. is air transported to another facility where he is pronounced brain dead and, seven days later at the request of his family, is removed from life support and passes. The following root cause analysis attempts to outline the key factors in Mr. B's deterioration and eventual demise, citing evidence in current literature as appropriate.

The most essential issue that contributed to the events leading to Mr. B's death is the lack of efficient use of human resources in the unit. Though additional staff was available, the details of the case make it clear that staff currently working in the emergency department were overwhelmed by the number of patients needing immediate attention or waiting to be examined. A more effective deployment of trained staff could very well have prevented the fatality that occurred.

The staffing shortage that resulted from this inefficiency prevented appropriate action being taken with the immediacy and directness that the situation warranted. Staffing shortages are one of the strongest predictors of poor patient care, and the inattentiveness of Nurse J. To Mr. B's initial alarms as the result of an increasingly crowded emergency department clearly contributed to the deterioration of Mr. B's condition and his death (Stanton, n.d.).

Training and review procedures are a third factor in the human resource issues that contributed to the outcome of this case. Nurse J's most recent review lists her as "meeting requirements" and notes that she is an experienced critical care nurse, yet she did not ensure adequate monitoring of Mr. B following his sedation. If her actions truly met requirements, those requirements must be reviewed; if her performance in this case did not meet institutional requirements, more rigorous and effective personnel review must be accomplished.

Stricter adherence to guidelines for moderate sedation is also required in this case, and failure to achieve this adherence by the attending physician and nursing staff was another causal factor in Mr. B's death. Such guidelines are meaningless unless they are rigidly and consistently followed, and it does not appear that the stated guidelines were fully implemented in this case.

Medical factors also contributed to the issues in this case. The procedure appears to have been rushed forward faster than was entirely necessary, which contributed to several other factors that had a direct impact on Mr. B's health and condition. This issue marks the intersection between human resource issues and medical issues in the case as described (Hoot & Aronsky 2008).

Over-administration of sedation clearly occurred, and the patient's potential nervousness might have contributed to increased blood pressure and thus led to a greater quantity of sedatives being administered than were needed. This is in part due to the speed with which the procedure was performed.

The patient's history does not appear to have been fully considered before sedatives were administered and other actions were taken. This at least in part a result of the lack of adequate staffing in the emergency department and the rush with which the procedure was accomplished. A better understanding of Mr. B's initial condition and previous history could potentially have reduced his risk exposure and led to a different course of action by staff.