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Conduct a Root Case Analysis

Students will review the following case and conduct a root cause analysis.

A 75-year-old female is an inpatient in bed #1 of Room 10 on a medical telemetry unit. She has been admitted for pneumonia. She is slightly confused. No family is with her in the hospital at this time. The nurse introduces herself to the patient, asks her if she needs anything right away, and says she will return shortly with the patient's medications. The nurse also has the patient in the other bed (bed #2) of the same room, the patient's roommate. The nurse is very busy because of the high patient load on the unit that night shift and due to being short one nurse who called out sick.

The nurse comes in to see the patient in bed #1 again and assess her and give her her medications. After the patient swallows all of the pills and is ready to get settled for the night to go to sleep, the nurse realizes that she just gave, to the patient in bed #1, the medications intended for the patient in bed #2.

Relevant Hospital Policies:

1) There should be at least five nurses on the unit on a night shift if the patient beds are full. Contact nursing supervisor ASAP if this is not the case.
2) Each patient's medications must be dispensed (taken out of the medication machine) and administered (given to the patient) individually. A nurse should not bring medicine to two patients at once.
3) All patient medications must be run through the electronic barcoding medication administration system prior to the patient taking them.
4) Before administering medication, the nurse should check two patient identifiers (name, date of birth, address, etc.). They are usually available in the medical record or on the patient identification band, or a competent patient can tell you too.
5) All patient medication errors must be reported via the hospital patient safety reporting system.

Solution Preview

Below is information regarding fishbone diagrams. Staff that should be present for the root cause meeting should be mentioned when answering this question. Be sure to mention how the meeting will be conducted (conference call, meeting, etc) and what instrument or instruments will be utilized as far as fishbone diagram, root cause analysis template etc.

Students will review the following case and conduct a root cause analysis.

The important thing to remember is that when conducting a root cause analysis you must identify the following:
1 - What is the problem
2 - Why did it occur (causes)
3 - How do we prevent it in the future
To do this, there are many useful tools to line out the information. Fishbone Diagrams are commonly used to diagram the event, its causes, the factors involved, and corrective actions. Below is information on fishbone diagrams and attached to the solution is a fishbone diagram as well as a root cause analysis template with the information from this incident filled in. Remember - there may be more than one cause of the problem, and getting to the actual ROOT of the problem means investigating and taking corrective actions to the point that the problem is prevented from reoccurring.

According to Galley (2013),

"In 1950s Japan, Kaurou Ishikawa became one of the first to ...

Solution Summary

Root cause analysis conducted with fishbone diagram for medication error during short staffed shift at healthcare facility.