Root Cause Analysis

Clinical Failure Assignment

1. Define “Just Culture” and its use in sentinel events? (5 pts)

2. Describe two possible processes that can be used during a Root Cause Analysis? (15 pts)

3. Using the Radonda Vaught case on the following page, identify the latent and active failures that contributed to this event. (30 pts)

4. Using the template, develop an action plan for each of the latent and active failures, including the job title of the responsible person and a date you would expect this to be completed (30 pts)

5. Discuss how just culture could have been used in this situation and the potential outcomes of doing such. Minimum 300 words (20 pts)

Radonda Vaught Case:

· Charlene Murphey, 75 years old was admitted for a brain injury. Was ordered to have a PET scan prior to discharge.

· Physician ordered 2 mg Versed IV for mild sedation related to claustrophobia.

· RN was orienting a new nurse at the time of this incident.

· At this time, the hospital had been suffering from technical difficulties with their Pyxis machines. The facility instructed personnel to use override function to access medications as needed.

· RN goes to Pyxis. Types in “VE”. No results were found.

· RN overrides Pyxis. Types in “VE”. Overrides prompts and selects Vecuronium.

· RN reconstitutes Vecuronium. Labels syringe Versed 1-2 mg. Placed in bd and brought to PET scan with patient.

· RN administered 1 mg via IV to the patient. The medication was not scanned as there was no scanner in the PET room. No documentation was recoded because there is not computer in the PET room.

· Patient underwent PET scan. Was unattended and unmonitored for 30 minutes.

· Patient experienced respiratory arrest. CPR was rendered but was unsuccessful.

· A second Rn discovered the viral in the bag and was able to determine that Vecuronium was given instead of Versed.

· Vanderbilt University Medical Center did not report the incident to the BON. Death was recorded as “natural death”. Vanderbilt settled with the family who signed a nondisclosure statement.

· An anonymous person reported the incident to Centers for Medicare & Medicaid, Tennessee Department of Health which then altered the Bureau of Investigation to be involved. This resulted in a Federal Case.

· RN was found guilty of reckless homicide and impaired adult abuse. 3 years probation.

Identify the Latent and Active Failures in this situation:

LATENT FAILURES

ACTIVE FAILURES

Equipment:

Training:

Policy/Procedure:

Culture:

Slips:

Lapses:

Mistakes:

Violations: