Root cause analysis of a sentinel event in hospital emergency department care

Mr. B Case Study

The case study in question which saw the loss of MR. B suggests many practical learning points in developing successful hospital emergency department (ED) procedures. This writing will propose a complete root cause analysis that takes into consideration of nine causative factors that led the sentinel event Mr. B's outcome. The factors will be listed in decreasing order of importance as it relates to the event.

Factor

The hospital appeared to be understaffed from all perspectives. At least 3 to 4 nurses and another 2-3 LPN's appeared to have been needed to suffice all the demands that were going on at that time. A simple back up staff was not enough.

Factor

Mr. B.'s narcotic addiction severely contributed to his ability to be sedated and complications were sure to follow.

Factor

The sedation policy must be reexamined as it may not be applicable any more. This policy should be continually monitored and updated.

Factor 9

In terms of life and death, little is known about the many circumstances behind either. In Mr. B's case the least important but most interesting idea behind the circumstance revolving around his death are of a spiritual and esoteric quality that defies medicine, logic or rational understanding.