Root cause analysis is a systematic approach used to identify problems within an event and create a plan to prevent the problem from recurring in the future. To be effective, a timeline of events is created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified as the reason for the event to occur. In the case of Mr B, an investigation into the events leading to his untimely death would be necessary. Once the problem is identified and described, event data is collected and formatted into a timeline. From the events, any problems in patient care that may have contributed to the final outcome are identified and determined whether they are causal. Appendix A outlines the chronology of the event. After examining the timeline of events surrounding Mr. B, there are several causal factors that led to this sentinel event. These include inadequate staffing, failure to identify worsening trends, failure to follow conscious sedation policy, inadequate observation and monitoring, failure to respond to alarms, inadequate assessment of home medications, dosage of medications, timing of appropriate medication administration, and failure to initiate cardiopulmonary resuscitation. in a timely manner. Inadequate emergency room staffing was a contributing factor in the event. A registered nurse (RN) and a licensed practical nurse (LPN) were on duty at the time of the incident. Additional staff were available and were not called. The Emergency Nurses Association believes there should be two registered nurses whose responsibility is to try...... half of the document...... control interactions. Retrieved June 11, 2011, from Drugs.com: http://www.drugs.com/drug-interactions/dilaudid-with-valium-1294-768-862-441.htmlNeedleman, J., Buerhaus, P., PKankratz , V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nursing staff and hospital mortality of patients. The New England Journal of Medicine, 364, 1037-1045. Nursing Spectrum Drug Manual 2009. (2011). The free dictionary. Retrieved June 11, 2011, from The Free Dictionary: http://medical-dictionary.thefreedictionary.com/idromorphone+idroclorideVolles, D.F. (2011, April 11). University of Virginia Health System adult and geriatric sedation/analgesia for diagnostic and therapeutic procedures. Retrieved May 12, 2011, from University of Virginia Health System: University of Virginia Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures