This paper conducts a root cause analysis of a sentinel event in which a patient (Mr. B) deteriorated fatally following procedural sedation in an emergency department. It identifies failures in policy adherence, staff training, and communication as contributing causes. The paper then applies Kurt Lewin's three-stage change model — unfreeze, transition, and refreeze — to propose a structured improvement plan. A Failure Mode and Effects Analysis (FMEA) framework is outlined to assess and prevent recurrence. Finally, the paper discusses the central role nurses play in advancing patient safety goals, improving bedside communication, and sustaining quality improvement initiatives within health care organizations.
The paper consistently applies theoretical frameworks to a specific case rather than discussing theory in the abstract. Each phase of Lewin's model and each step of the FMEA process is explicitly mapped back to the events surrounding Mr. B, demonstrating applied analysis — a core skill in health care management and nursing leadership courses.
The paper opens with a factual reconstruction of the sentinel event and identifies three policy/procedural failures through targeted questions. It then introduces Lewin's change model and walks through all three phases as a change-management roadmap. Next, it describes the FMEA methodology and applies each of its three steps to the case. The paper closes by establishing nurses as the primary agents of sustained quality improvement, connecting bedside practice to organizational goals.
Due to a sentinel event that occurred, a root cause analysis is being conducted. The central problem that must be examined is how Mr. B went from resting without any indication of discomfort or distress to not breathing and having no palpable pulse in a matter of fifteen minutes.
After the reduction of the patient's left hip was completed at 4:30, he was placed on an automatic blood pressure machine programmed to monitor his blood pressure every five minutes, along with a pulse oximeter. He was not receiving supplemental oxygen, nor were his ECG and respirations being monitored. The current hospital moderate sedation/analgesia ("conscious sedation") policy requires that a patient remain on continuous blood pressure monitoring, ECG, and pulse oximetry throughout the procedure and until the patient meets specific discharge criteria. That criteria includes the patient being fully awake, vitals stable, no nausea or vomiting, and able to void. These criteria were clearly not being met by Mr. B.
Another issue that must be examined is that at 4:35, when staff left Mr. B's room, his blood pressure was 110/62 and his oxygen saturation was 92%. When an alarm was heard and the LPN entered Mr. B's room, the monitor was registering a "low O2 saturation" reading of 85%. The LPN reset the alarm and repeated the blood pressure reading but never addressed the low oxygen saturation warning.
At the time these events were unfolding, the supervising physician and the LPN on duty had received an emergency transport patient. They were also in the process of discharging two other patients, and the ED lobby had become congested with new incoming patients. Even though additional backup staff was available on that day, no one was called.
The first question that must be asked is why the hospital's moderate sedation/analgesia policy was not followed. The policy clearly states that the patient must remain on continuous ECG monitoring until a predefined set of discharge criteria are met. Mr. B had not met those criteria and should never have been left without ECG monitoring. The second question is why, when the alarm sounded the first time, the LPN simply reset it rather than addressing the low oxygen saturation warning that was being presented.
Hospital policy dictates that all practitioners who perform moderate sedation must first successfully complete the hospital's moderate sedation training module. It is noted that the supervising physician had successfully completed this training, but there is no mention that the LPN had done so. The low oxygen saturation warning should have been addressed by someone — such as the supervising physician — who was properly trained in this area.
The final question that should be raised is why, if backup staff was available when the ED became busy, that staff was not called upon. Is there a defined threshold at which hospital policy requires staff to call for reinforcements, and who is responsible for making that decision? Working under extremely busy circumstances greatly compromises the quality of care delivered to patients. If there is something that can be done to alleviate such a situation, it should be done.
In the case of Mr. B's death, several root causes must be remedied to prevent recurrence. First, all hospital procedures and policies need to be not only well documented but also accessible to all who need them. They must be adhered to at all times, and employees must be held accountable for knowing what the standard operating procedures are and when they must be followed. A second cause involves the need for all personnel working with patients to be fully trained in every procedure required to carry out their job functions. If a person finds themselves in a situation for which they have not been properly trained, a policy must be in place directing them to consult someone who is trained, in order to ensure that proper care is delivered at all times.
In the early twentieth century, psychologist Kurt Lewin identified three stages of change that are still used in many change theories today. The three phases are unfreeze, transition, and refreeze. A basic inclination of people is to seek situations in which they feel relatively safe and in control. When they establish themselves in such situations, they often attach their sense of identity to their environment. This creates a relaxed stasis from which alternatives — even those that may offer significant benefit — will cause discomfort. Unfreezing people from this phase usually requires push methods to get them moving, after which pull methods can be used to keep them going (Lewin's freeze phases, 2010).
A key element of Lewin's model is that change, even at the psychological level, is a journey rather than a simple step. This journey may not be easy, and a person may need to pass through several stages before reaching the other side. Transitioning requires time. Leadership is critically important to the entire change process. Some form of coaching, counseling, or other psychological support will often be needed to help with the transformation. People often become comfortable in temporary situations where they are not held accountable for the demands of normal work and where talking about change may be substituted for real action (Lewin's freeze phases, 2010).
At the other end of the process, the goal is to refreeze — to put down roots again and establish a new place of stability. In reality, refreezing is often a slow process, as transitions seldom stop cleanly. They proceed more in fits and starts, with long periods of incremental progress. There is both good and bad in this. The hazard that many organizations have encountered is that people fall into a state of "change shock," working at a low level of competence and effectiveness while awaiting the next change (Lewin's freeze phases, 2010).
When applying change theory to the current situation, it is important to ensure that each of the three phases is included in a change plan. It is evident that the staff had achieved a comfortable stasis from which any alternatives, even beneficial ones, caused discomfort. The key to the unfreezing phase is convincing staff that current practices are not working and that change is necessary to improve the situation. A push is needed to get people talking. A good starting point would be to form a process improvement committee charged with reviewing existing standard operating procedures, identifying which need to be updated, determining which are missing and must be defined, and developing a method for distributing updated procedures to staff so they can be held accountable.
Once the review of standard operating procedures is complete, they must be distributed to every employee and training sessions must be held. This transition phase must be led by leadership to ensure that everyone is aligned. This is also the appropriate phase in which to incorporate coaching, counseling, or other psychological support to help employees embrace change. It must be reinforced that the process improvements being undertaken are for the benefit of everyone, and especially for patient safety and satisfaction. Everyone must embrace the changes because patient safety should be the hospital's top priority, and situations like the one that occurred with Mr. B should never happen again.
Once all processes and procedures have been defined, documented, and distributed to staff, it is time to move into the refreezing phase. This phase involves ensuring that everyone is following the established processes. A measurement instrument must be devised to monitor compliance. This could consist of random audits conducted by leadership to verify that everything is being done correctly. Both a system of rewards and a system of consequences must be established and consistently applied in response to audit findings. In order for employees to embrace the changes, they must know from the outset that there are consequences and that they will be held accountable for their actions.
After the change process has been developed, a Failure Mode and Effects Analysis (FMEA) must be conducted. This analysis projects the likelihood that the process improvement plan will not fail. The interdisciplinary team for this entire process will consist of an emergency room physician, a registered nurse, an LPN, a clinical quality consultant, an HR representative, and a patient safety advocate.
Nurses Play Key Role In Improving Quality Of Patient Care. (2010). Retrieved March 25, 2010, from Medical News Today Web site:
Runy, Lee Ann. (2008). The Nurse and Patient Safety. Retrieved March 25, 2010, from Hospitals and Health Networks Web site:
You’re 56% through this paper. Sign up to read the remaining 2 sections.
Sign Up Now — Instant Access Already a member? Log inAlways verify citation format against your institution’s current style guide requirements.