Patient safety is not only the responsibility of the nurse-using root cause analysis: To explore the patient’s unexpected death

26^th World Congress on Nursing Care

May 21-23, 2018 Osaka, Japan

Hsiang-Lei Shin

Kaohsiung Hospital, Taiwan

Posters & Accepted Abstracts: J Nurs Care

Abstract :

Aim: This article describes a patient�s sudden unexpected death due to fever for less than 24 hours from admission. The review process suspects that the patient has died as a result of chewing betel nuts causing choking. Finally, the use of RCA to find the root cause and improve the program, to provide medical staff attention and prevention. Method: As a serious and sentinel event, an investigation team was established. Key participants were identified and RCA was implemented systematically with a trained facilitator guiding each analysis step. Chronological narratives were tabulated in a timeline sheet. Why tree and barrier analysis were used to determine the root factors of this event. Result: Two root causes of the patient with fever due to sudden unexpected death event were identified, which included: (1) Patient factors: Refusing to influenza screening and while coughing while chewing betel nut and (2) relevant education and training inadequate. Conclusion & Significance: RCA is a tool for improving the effectiveness of hospital medical abnormalities. However, the patient�s sudden unexpected death is not the responsibility of the nurse as she is involved in the review care process only. In case of nursing manpower shortage, this process caused more frustration and helplessness; it�s worthy to pay attention of the hospital management unit.

Biography :

Hsiang-Lei Shin is a Registered Nurse of the Kaohsiung Hospital in Taiwan. She has 13 years of experience in cardiology, gastroenterology, hepatobiliary, chest, nephrology and infectious diseases.
Email:yuh3850@gmail.com