Question

Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis.

As the RCA for this case begins, the team struggles with identification of the root causes of the outcome. They consider the patient's characteristics as well as the work environment. According to Charles Vincent, what other areas should they consider?

A. Team factors, institutional context, and organizational factors
B. Budget, human nature, and organizational factors
C. Team factors, human nature, and PDSA cycles
D. Psychology, PDSA cycles, and management factors

Answer 1

A. team factors, institutional context, organizational factors

Step-by-step explanation:

Root cause analysis is being don in the case of Prathibha, who is a young woman and got respiratory failure while recovering from knee surgery in PACU. Characteristics of patients as well as the work environment was taken under consideration but team factors, institutional context and organizational factors shall also be considered, they also could be the reasons of respiratory failure of the patient, it may be due to excessive dose of anesthesia or something else that could be the fault of team or organization.