Root Cause Analysis
Root Cause Analysis
Root Cause Analysis
Maya Mendez
28 June 2020
ROOT CAUSE ANALYSIS 2
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
2. Identify the team members who would assist in conducting the root cause analysis
team that is meant to process and identify the root cause of an event that resulted in
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
instructors, other staff nurses, health care professionals, and with the patients.
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
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
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
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
References
Dingley, C., Daugherty, K., Derieg, M. K., & Persing, R. (n.d.). Improving patient safety through
https://www.ncbi.nlm.nih.gov/books/NBK43663/#advances-dingley_14.rl1
Guidance for performing root cause analysis (RCA) with performance improvement projects
certification/qapi/downloads/guidanceforrca.pdf
Huber, D. L. (2018). Leadership and Nursing Care Management. (6th ed.). St. Louis,