You are a member of your organization’s CPR Committee. One committee responsibility is to review all rapid response team (RRT) documents to determine if the RRT was an appropriate action and what follow-up steps are necessary. The first review is an 80-year-old patient admitted for abdominal pain found to have ulcerative colitis. The patient had a bowel resection with an uneventful postoperative recovery period. On the second postoperative day, however, an RRT was called based on assessment findings of a pulse of 130, blood pressure (BP) 70/30, and PulseOx 87%. The patient had been completely oriented but is now disoriented to place and time. During the RRT, the patient was given a liter of normal saline and transferred to the ICU. The patient’s condition worsened in the ICU, leading to intubation. The CPR Committee has asked you as the nurse committee member to present this case to the Committee. In preparation, you begin by reviewing medication administration records in the EMR. Although antibiotics were ordered, three postop doses were not documented as given. Morphine Sulfate was ordered and given consistently every 6 hours for postoperative pain as prescribed. Because of time, your initial preparation ends.

1.

To continue preparation for your presentation to the Committee, what additional clinical information would you evaluate before the Committee meeting to effectively present this case?

2.

In addition to clinical data, what nonclinical other data would you need to evaluate to determine appropriateness of the RRT?

3.

After your overview, which includes the nurse who called the RRT and did follow the RRT procedure, the chair of the Committee asks for your judgment and recommendations:

a.

What recommendation would you, the nurse, make regarding appropriateness of the RRT based on the RRT procedure?

b.

While reviewing the case, what cues did you identify as potential root causes that may have precipitated this outcome? Identify four potential root causes from the scenario.

c.

Would you recommend this Committee should refer this case for an official RCA to be conducted?