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C489 Root Cause Analysis A root cause analysis is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. (Risk & Reliability Division, ABS Group, Inc., 2017) The final outcome for this scenario is

A.    Root Cause Analysis

A root cause analysis is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. (Risk & Reliability Division, ABS Group, Inc., 2017)  The final outcome for this scenario is that Mr. B died an unnecessary death. Mr B. died due to the lack of oxygen to the brain and ventricular fibrillation. Upon initial assessment of Mr. B. His vital signs were within normal limits. His oxygen levels at that time were good enough that he didn’t require supplemental oxygen. Mr. B was given an increased amount of sedation meds to block his pain which were a direct effect for decreased O2 levels and hypotension

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