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No brief between surgery and ICU team Consent with medical and
surgical history
Policy to look at chart and history
Lack of check list
Lack of form of consent for
procedures
Materials
Methods
Root Cause Analysis
Jerry died from sepsis and multiple organ dysfunction WHY?
Patient was administered vasopressors on the right femoral line despite
remaining hemodynamically unstable with a right transplanted kidney WHY?
The ICU team was not notified that the patient had a right transplanted kidney
and placed a right femoral central line (Contraindicated) WHY?
The interdisciplinary communication system did not allow the ICU and
Surgical team to discuss the history of a right kidney transplant
Actions to Prevent Further Occurrence
Who: All multidisciplinary hospital staff members involved in procedures on
patients (nurses, physicians, techs and aids). At least 1 member from each
department required and patient.
How: Physician performing procedure will order the procedure and include
correct service with description and location specified. Order will be printed in the
form of a bar code. The wristband of the patient will be scanned, and the
procedure barcode will be scanned. At the bedside, members indicated will
discuss, review and agree, and then sign off before continuing.
Evaluation of Action
Intermediate
Correct
Patient safety
RN communication to
Physicians prevent surgical
error
U.S. Department of Veterans Affairs. (2015). VA National Center for Patient Safety
RCA Tools