Root Cause Analysis of what led to the Demise of Mr. B. (Causative factors, errors, and hazards) Hazard 1: the dog lying in Mr. B’s path so that Mr. B could not see it, leading to Mr. B’s fall
Hazard 2: Mr. B’s use of oxycodone could not permit his sedation with regular dosage of diazepam or hydromorphone
Hazard 3: Mr. B was also overweight, and this had a deleterious effect on the ability to sedate him using the regular dosages of IVP diazepam or hydromorphone. The chief causes and errors leading to Mr. B’s death seem to have been the fact that there were two large doses of two different sedatives used on him, ...
