Eky Discussion The Problem Of The Pediatric Study Was That T

Eky Discussionthe Problem Of The Pediatric Study Was That The Patient

Eky Discussion: The problem of the pediatric study was that the patient had notified the RN about his hand hurts, but the RN dismissed the concern and told him it is related to the IV running. Further investigation revealed that the RN did not follow proper procedure and placed the IV in the wrong part of Liam’s hand. Despite seeing a hard stop notification in Liam’s chart, the RN dismissed it. The RN reached out to a physician for a consult on the IV site wound, but the consultation was delayed for six hours. An RCA (Root Cause Analysis) framework was employed because an incident occurred under medical care.

RCA is used to determine why an unexpected or unintended outcome occurred (Haney, 2020). The team investigated whether organizational errors or individual errors contributed to Liam’s injury by examining communication, staff fatigue, environment, equipment, and organizational policies. The team included leadership representatives from Quality, Risk Management, Nursing, and ancillary departments, plus care team members familiar with IV extravasation, to objectively evaluate the root causes.

The root cause analysis identified multiple factors: the RN placed the IV incorrectly, dismissed safety warnings, and delayed in seeking urgent consultation. The RN also failed to adhere to hospital policies requiring check-ins every two hours. These failures led to necrosis on Liam’s hand, affecting his dominant hand’s function. The RCA’s purpose was to improve quality and prevent similar incidents, which it achieved by developing an action plan that included regular evaluations and audits of the implemented procedures (Haney, 2020).

This incident exemplifies a reactive approach, as it addressed failures after harm occurred. I agree with the RCA’s selection because it provided insight into organizational vulnerabilities, emphasizing systemic changes over individual blame. The RCA’s recommendations focused on fostering a safety culture, improving communication, enforcing protocols, and conducting ongoing audits to ensure compliance and prevent recurrence.

References:

Haney, K. (2020). Root Cause Analysis: A Pediatric Case Study. Journal of Legal Nurse Consulting, 31(4), 26–29.