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While hospitalized on a cardiac step-down unit, a patient undergoing cardiac monitoring died when a lethal cardiac rhythm was missed by the hospital staff. Because of the severity of the outcome, a root cause analysis (RCA) was done. The root cause analysis determined the central monitor screens for the cardiac units were at the nurses\u2019 stations, giving them primary responsibility for oversight. However, the RNs were so busy that the unit secretaries were eventually trained to watch the monitors because they sat at the desk where the monitors were located.<\/span><\/p>\n\n

The unit secretaries were also very busy, making it impossible to keep a constant eye on the cardiac monitors resulting in inconsistent monitoring, reporting, and follow-up related to monitor alarms. <\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"5b7a1b20-45ad-4652-ad08-355cbcbde72f"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.47612179487179,"y":89.24500179116698,"width":5.448717948717949,"height":10.759493670886075,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd68f248ec.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"next"},"subContentId":"feea45f0-d221-4a39-a9a4-a19f19c62979","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.47612179487179,"y":88.57056962025315,"width":5.448717948717949,"height":11.39240506329114,"goToSlide":1,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"next","invisible":false,"title":"next"}],"slideBackgroundSelector":{}},{"elements":[{"x":20.79744816586922,"y":3.166908517350157,"width":76.71451355661883,"height":96.84542586750788,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"

During the RCA, it was determined that the nurses did not intend the secretaries to be the only pair of eyes on the monitors and had every intention of being closely involved. Secretaries were instructed to notify the RN of any monitor alarm, and it was the nurse\u2019s responsibility to respond. However, when the nurses assigned the responsibility to the secretaries, they became complacent of their primary responsibility to ensure someone observed, reported, and responded to any alarm. I<\/span><\/p>\n\n

n the case of the death, the secretary had learned to silence the monitors once she had alerted the nurse because the noise was overwhelming. The secretary reported, \u201cI had seen the nurses do it all the time because they often complained that patients turning over could cause the alarms to go off.\u201d This statement was corroborated by the nursing staff, and they admitted they often instructed the secretaries to \u201cshut it off,\u201d based on their having just been in the patient\u2019s room several times for monitor alarms and the patient was fine.<\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"0d1366ed-2519-4747-a426-c3227477e5c5"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.4761217948718,"y":89.24500179116698,"width":5.448717948717949,"height":10.759493670886075,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd68f248ec.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"next"},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"3bb91ccf-fda9-4c0f-9592-323ac7a6cfea"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":0,"y":88.57056962025315,"width":5.769230769230769,"height":11.39240506329114,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd6b5ba718.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"baack"},"subContentId":"bfa4d78b-843e-4932-8e68-9d030c2c4b76","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.55128205128204,"y":88.60759493670885,"width":5.448717948717949,"height":11.39240506329114,"goToSlide":1,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"next","invisible":false,"title":"next"},{"x":0,"y":88.60759493670885,"width":5.448717948717949,"height":11.39240506329114,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"previous","invisible":false,"title":"back"},{"x":1.721170395869191,"y":3.4013605442176873,"width":17.211703958691913,"height":30.612244897959183,"action":{"library":"H5P.Image 1.1","params":{"decorative":true,"contentName":"Image","file":{"path":"images\/file-63fe4b08645f1.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":774,"height":700,"originalImage":{"path":"images\/file-63fe4ae886dcf.jpg#tmp","mime":"image\/jpeg","height":3744,"width":5616}}},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"14406942-e56d-437b-bef9-7e0c4cc487d9"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":3.442340791738382,"y":6.802721088435375,"width":75.73149741824442,"height":91.15646258503402,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"

On the day of the event, the monitor was alarming and the secretary told the nurse as usual, but on her way to the patient\u2019s room, the nurse was called to an emergency at the other end of the hall, preventing her from checking the patient immediately. The secretary silenced the alarm on two subsequent times once she had notified the nurse, thinking it had been addressed. The patient had been in ventricular fibrillation and died before the nurse returned to the room.<\/span><\/p>\n\n

During the investigation, it was discovered there had been five other incident reports filed for similar problems over the past 2 years, including two near-death cases. In a review of the other incident reports, it was documented that the solution to the early problems had been to train the secretaries as a backup because the nurses were often in the hallways or in patients\u2019 rooms. <\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"0291062a-f524-4fa5-9971-0eb8c85a7efa"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.4761217948718,"y":89.24500179116698,"width":5.448717948717949,"height":10.759493670886075,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd68f248ec.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"next"},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"94b81b37-2bcc-467e-a22e-94d07831822c"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":0,"y":88.57056962025314,"width":5.769230769230769,"height":11.39240506329114,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd6b5ba718.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"baack"},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"253de3c6-1eff-4694-83a7-11b371ca0a19"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":94.55128205128204,"y":88.60759493670885,"width":5.448717948717949,"height":11.39240506329114,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"next","invisible":false,"title":"next"},{"x":0,"y":88.60759493670885,"width":5.448717948717949,"height":11.39240506329114,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"previous","invisible":false,"title":"back"},{"x":80.89500860585198,"y":3.4013605442176873,"width":17.211703958691913,"height":30.612244897959183,"action":{"library":"H5P.Image 1.1","params":{"decorative":true,"contentName":"Image","file":{"path":"images\/file-63fe4b08645f1.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":774,"height":700,"originalImage":{"path":"images\/file-63fe4ae886dcf.jpg#tmp","mime":"image\/jpeg","height":3744,"width":5616}}},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"9aa3d91d-c9c3-410e-8c4b-1e9638a485fc"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":20.654044750430295,"y":3.4013605442176873,"width":76.76282051282051,"height":91.13924050632912,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"

It was believed that having someone who was always near the monitors and who could watch them and report alarms to the nurses would solve the problem. It became clear, based on the recent death, that a more drastic solution was needed. After analyzing several proposed solutions, it was decided that having a centralized monitor room separate from the nursing station monitors and staffed with monitor techs was the best solution. <\/span><\/p>\n\n

In addition to the centralized monitor room, the ability to silence a monitor was removed from the central unit at the nurses\u2019 station, so the alarm could only be silenced by an RN at the patient\u2019s bedside to ensure someone had seen the patient before silencing the alarm. Finally, in the event of a lethal alarm, the monitor room techs would call a code blue before phoning the nursing unit.<\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"48027d65-725c-4d45-8e28-0925137bfb4b"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":0,"y":88.57056962025314,"width":5.769230769230769,"height":11.39240506329114,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-63ebd6b5ba718.png","mime":"image\/png","copyright":{"license":"U"},"width":100,"height":100},"alt":"baack"},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"d99416dc-db9b-428c-9f7c-70f231f9560c"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":0,"y":88.60759493670885,"width":5.448717948717949,"height":11.39240506329114,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"previous","invisible":false,"title":"back"},{"x":1.721170395869191,"y":3.4013605442176873,"width":17.211703958691913,"height":30.612244897959183,"action":{"library":"H5P.Image 1.1","params":{"decorative":true,"contentName":"Image","file":{"path":"images\/file-63fe4b08645f1.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":774,"height":700,"originalImage":{"path":"images\/file-63fe4ae886dcf.jpg#tmp","mime":"image\/jpeg","height":3744,"width":5616}}},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"231dc09b-bc18-4824-9a32-81cdac3cbfa2"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}}],"keywordListEnabled":true,"keywordListAlwaysShow":false,"keywordListAutoHide":false,"keywordListOpacity":90,"globalBackgroundSelector":{"fillGlobalBackground":"#ffffff"}},"override":{"activeSurface":false,"hideSummarySlide":false,"summarySlideSolutionButton":true,"summarySlideRetryButton":true,"enablePrintButton":false,"social":{"showFacebookShare":false,"facebookShare":{"url":"@currentpageurl","quote":"I scored @score out of @maxScore on a task at @currentpageurl."},"showTwitterShare":false,"twitterShare":{"statement":"I scored @score out of @maxScore on a task at @currentpageurl.","url":"@currentpageurl","hashtags":"h5p, course"},"showGoogleShare":false,"googleShareUrl":"@currentpageurl"}},"l10n":{"slide":"Slide","score":"Score","yourScore":"Your Score","maxScore":"Max Score","total":"Total","totalScore":"Total Score","showSolutions":"Show solutions","retry":"Retry","exportAnswers":"Export text","hideKeywords":"Hide sidebar navigation menu","showKeywords":"Show sidebar navigation menu","fullscreen":"Fullscreen","exitFullscreen":"Exit fullscreen","prevSlide":"Previous slide","nextSlide":"Next slide","currentSlide":"Current slide","lastSlide":"Last slide","solutionModeTitle":"Exit solution mode","solutionModeText":"Solution Mode","summaryMultipleTaskText":"Multiple tasks","scoreMessage":"You achieved:","shareFacebook":"Share on Facebook","shareTwitter":"Share on Twitter","shareGoogle":"Share on Google+","summary":"Summary","solutionsButtonTitle":"Show comments","printTitle":"Print","printIngress":"How would you like to print this presentation?","printAllSlides":"Print all slides","printCurrentSlide":"Print current slide","noTitle":"No title","accessibilitySlideNavigationExplanation":"Use left and right arrow to change slide in that direction whenever canvas is selected.","accessibilityCanvasLabel":"Presentation canvas. 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This model case illustrated a system failure that did not meet the major attributes of health care quality of being safe, patient-centered, timely, effective, and efficient. This effort would be classified as a sentinel event because there was a severe variation in the standard of care caused by both human error and system error, resulting in death.<\/span><\/p>\n"},"library":"H5P.AdvancedText 1.1","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"82118408-af9e-4007-a00e-810f78231534"},"useSeparator":"auto"}]},"library":"H5P.Column 1.15","metadata":{"contentType":"Column","license":"U","title":"Case Analysis"},"subContentId":"28985da1-09c2-41de-9378-ed1204d78824"},{"params":{"content":[{"content":{"params":{"text":"

What can a root cause analysis accomplish?<\/span><\/li>\n\t
In this case study, what must occur after the changes described have been implemented to ensure a culture of quality is maintained?<\/span><\/li>\n\t
What attributes of quality are being utilized in order to improve practices?<\/span><\/li>\n<\/ul>\n"},"library":"H5P.AdvancedText 1.1","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"37d6af60-6980-4569-8811-664b018c376e"},"useSeparator":"auto"}]},"library":"H5P.Column 1.15","metadata":{"contentType":"Column","license":"U","title":"Guiding Questions"},"subContentId":"e5cf798c-6716-4123-aa91-fabbbf5ed549"}],"behaviour":{"tabPlacement":"dynamic","tabSpread":70,"colorBackground":"rgba(255, 255, 255, 0)"},"l10n":{"tab":"tab","noContent":"There is no content to be displayed."},"a11y":{"tabLsist":"Choose a tab."}}

trentu - IENC1107 week 3 case study

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