Write a 5-7 page Root Cause Analysis (RCA) and corrective action for the clinical event. Include: a problem statement including a description of the problem, staff involved, and a suggestion for RCA team members.

Margaret is an elderly woman who has been admitted to a medical center for breathing problems. She has some trouble hearing and has some memory problems as well.
Peter is a well-respected nurse on a medical unity. He has been working there for five years and he has recently been helping new nurses get oriented to work in his part of the hospital. Today he is working with Amy, a new graduate who just passed NCLEX and received her RN.
Jorge, a respiratory therapist, is called to see Margaret to help with her breathing. He notes that she is not getting enough oxygen using the nasal prongs and he switches her to an oxygen mask, which improves her symptoms. Jorge sees Peter in the hallway and says, Hey Peter I just upped her oxygen as they pass in the hallway to their next tasks. It is a busy day for Jorge, so figures he will write his notes in the chart later.
At 3pm Margaret is scheduled to go for a test in the radiology department on the other side of the hospital. Teddy, the patient transporter, arrives to take Margaret to her test. Peter, the nurse is in another patient room assisting one of the doctors with the placement of a sterile central line. When Teddy asks if there are any special concerns with Margaret, Amy, the new nurse, replies, No, she is all set. If Amy had been told about Margarets oxygen mask, she would have accompanied her to the test.
While being transported, Margaret knocks her mask off her face. When she arrives in the radiology department for her test, she is not breathing. The code team is called, but they are not able to revive her.
Source: Institute for Healthcare Improvement Open School. Retrieved from www.ihi.org/education/IHIOpenSchool/resources/Pages/CaseStudies/default.aspx

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