Root Cause Analysis

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The key takeaways are that ineffective communication between nurses led to a medication error, and policies and procedures were not properly followed. Standardizing handoff reports using SBAR and emphasizing the importance of policies could help prevent similar errors.

A student nurse administered insulin that had already been given by the night shift nurse after being told to by the day shift nurse. Contributing factors were a lack of documentation by the night nurse, unavailable instructor, and pressure to give the medication on schedule.

A nurse leader, the clinical instructor, student nurse, day and night shift nurses would be involved. Their perspectives are important to understand what occurred and how to improve processes. The event also provides a learning opportunity.

Running head: ROOT CAUSE ANALYSIS 1

Root Cause Analysis

Grand Canyon University: NSG-436

Maya Mendez

28 June 2020
ROOT CAUSE ANALYSIS 2

Root Cause Analysis

1. Provide a brief description of the problem and a detailed summary of contributing

factors identified in your root cause analysis diagram

A student nurse was approached by their assigned nurse requesting that they

draw up and administer two units of regular insulin. It was discovered that there was

no record of the prior nurse administering the insulin but there was documentation of

a blood sugar at 0600. As for the student, according to their program’s policy, they

are required to check that the dose, medication, client, time, and route are all correct

prior to administration with their instructor but the instructor was unavailable. The

staff nurse reinforced the importance of administering the insulin at the scheduled

time and stated to observe the student. Once the insulin type and dose were verified

by the nurse, the student nurse administered it at 0730 while still under the nurse’s

supervision. While the student was documenting they had discovered that the night

shift nurse retroactively administered two units of regular insulin at 0700. The patient

was immediately notified as well as the clinical instructor and unit nurse. The patient

was given orange juice and breakfast and was monitored for signs and symptoms of

hypoglycemia in addition to their blood sugar being checked 30 and 60 minutes after

the insulin was administered. Despite the client’s blood glucose levels to be within

normal limits, the student and instructor completed an incident report under the

supervision of the staff nurse.

2. Identify the team members who would assist in conducting the root cause analysis

and why their inclusion is beneficial to the team.


ROOT CAUSE ANALYSIS 3

A root cause analysis team is a structured and facilitated, multidisciplinary

team that is meant to process and identify the root cause of an event that resulted in

an undesired outcome and to develop corrective actions (Guidance, n.d). Regarding

this specific situation, a nurse leader or nurse manager would be involved when

conducting the root cause analysis. The leader/manager should be able to remain

neutral about the event as they will be involved with interviewing the participants

and other witnesses to the event. With that being said, the clinical instructor, student

nurse, day and night shift nurse would all be involved as well. The clinical instructor

can help guide the student nurse to speak up as well as become aware of what the

process looks like when a medication error has occurred. It can be a great learning

opportunity for the student as well as a great opportunity for the instructor to teach

the other student nurses in the group. The night shift nurse would be interviewed on

what had occurred and why documentation was not done immediately. The unit

nurse would then be interviewed on why further evaluation was not done when

looking in the patient’s chart as well as why she did not feel the need to fill out an

incident report. Both nurses would be educated on the use of SBARs and well as the

importance of having clear and effective communication with student nurses,

instructors, other staff nurses, health care professionals, and with the patients.

3. Include a minimum of two recommendations for proposed action to eliminate the

problem from reoccurring.

Ineffective communication among nurses and health care professionals is said

to be one of the leading causes of medical errors and patient harm. According to a

report from the Joint Commission, they revealed that communication failures were
ROOT CAUSE ANALYSIS 4

implicated at the root of over 70 percent of sentinel events (Dingley & Persing, n.d.).

In this scenario communication between the night shift nurse and day shift nurse

could be improved to ensure that such an error does not reoccur. I would recommend

that the unit implement the standardized tool of an SBAR while giving a handoff

report. An SBAR is a communication technique that helps members of the health

care team communicate effectively so that appropriate decisions can be made (Huber,

2018).  This tool would have allowed either the night shift nurse to communicate

what medications were given, which were held, and which need to be given or it

would have given the day shift nurse the opportunity to ask such questions. Another

recommendation I would propose to eliminate the problem from reoccurring is

stressing the importance of policies as both the unit nurse and student nurse looked

passed their policies. What was unknown by both was that the medication was

already administered, it was just retroactively charted at a different time. If the nurse

would have taken the time to slow things down and look further into the client’s

chart, they could have found that it was administered or perhaps if the night shift

nurse documented right after administration, not only would it ensure that they were

following the new policy to administer medications in compliance to physician-

ordered scheduled times but it would have ensured that it was documented in the

correct location. As for the student nurse, they should have discussed with the unit

nurse that they cannot administer without reporting to their clinical instructor as they

need to verify the six rights with them. Policies are vital in healthcare as they set a

general plan of action, provide guidelines, and clarity when dealing with issues that
ROOT CAUSE ANALYSIS 5

are critical to health and safety. In addition, they allow for an understanding of roles

and responsibilities within an organization.

References

Dingley, C., Daugherty, K., Derieg, M. K., & Persing, R. (n.d.). Improving patient safety through

provider communication strategy enhancements. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK43663/#advances-dingley_14.rl1

Guidance for performing root cause analysis (RCA) with performance improvement projects

(PIPs). (n.d.). Retrieved from https://www.cms.gov/medicare/provider-enrollment-and-

certification/qapi/downloads/guidanceforrca.pdf

Huber, D. L. (2018). Leadership and Nursing Care Management. (6th ed.). St. Louis,

MO: Elsevier-Saunders. ISBN-13: 9780323389662

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