The scenario with Mr. B., the root cause analysis suggested that inadequate staffing and insufficient training as the leading root to this sentinel event. Change theory would guide us to form relationships with everyone involved and support trusting nonjudgmental attitudes. Enabling all parties to work together closely and help find solutions. Next would be gathering of data in regards to how often they work short staffed and how staff overall feels about staffing issues. After obtaining sufficient amount of data, the group and management should hold a meeting to discuss the issues. The main focus of this meeting is to find solutions to this never (sentinel) event. Once everyone is in agreement, working on implementing change and refreezing of the new system can occur. Most large unit facilities (60-bed unit in this scenario) have a nursing supervisor or charge nurse who oversees workflow of the unit. As the patient load in the ER of this scenario grew beyond the limits of what the present staff was able to handle safely the nursing supervisor should have been notified. This will be implemented into the change plan with protocol
The scenario with Mr. B., the root cause analysis suggested that inadequate staffing and insufficient training as the leading root to this sentinel event. Change theory would guide us to form relationships with everyone involved and support trusting nonjudgmental attitudes. Enabling all parties to work together closely and help find solutions. Next would be gathering of data in regards to how often they work short staffed and how staff overall feels about staffing issues. After obtaining sufficient amount of data, the group and management should hold a meeting to discuss the issues. The main focus of this meeting is to find solutions to this never (sentinel) event. Once everyone is in agreement, working on implementing change and refreezing of the new system can occur. Most large unit facilities (60-bed unit in this scenario) have a nursing supervisor or charge nurse who oversees workflow of the unit. As the patient load in the ER of this scenario grew beyond the limits of what the present staff was able to handle safely the nursing supervisor should have been notified. This will be implemented into the change plan with protocol