NSG 436 RS Root Cause Analysis Template PDF

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Summary

Cause Analysis...

Description

Provide a 150-200-word summary that includes the following: 1. Provide a brief description of the problem and a detailed summary of contributing factors identified in your root cause analysis diagram 2. Identify the team members who would assist in conducting the root cause analysis and why their inclusion is beneficial to the team. 3. Include a minimum of two recommendations for proposed action to eliminate the problem from reoccurring.

1. During clinical rotations, a student was provided the opportunity to administer insulin to a diabetic patient. However, the policy through the school and hospital was that the student’s clinical instructor was to be present during the administration, so this is the first apparent problem presented. The new hospital policy was on a strict regimen to administer medications within a certain time frame, so when the student was to administer the insulin, her instructor was not present. On top of that problem, there was no previously recorded insulin administration from the previous night shift nurse, but a blood sugar had been taken at 0600, so the staff nurses assumed it was okay to administer, however after the student nurse administer the 2 units of insulin under another staff member’s supervision at 0730, that previous nurse charted that she gave the patient 2 units of insulin 30 minutes prior. So, the main three problems in the scenario are a breach in policy, a double dose of insulin given and risk of hypoglycemia for the patient.

2. Team members that would be vital in assisting and conducting the root cause analysis would be the student nurse, staff nurse, clinical instructor, patient, and charge nurse. The student nurse, staff nurse and patient are necessary in assessing the root of the problem because they were the ones involved in the immediate care and response of the situation. The student was responsible for the policy of having the clinical instructor present, the staff nurse responsible for the SBAR from the previous shift and information about the patient’s medications and administrations, and the patient is involved because they were at an increased risk for hypoglycemia. Lastly, the clinical instructor and charge nurse should be involved for more of a liability aspect and taking responsibility for the people under their supervision.

3. The first recommendation that came to mind in eliminating this problem in the future is COMMUNICATION. A simple SBAR would have sufficed, for example the oncoming nurse should have asked specifically about insulin and blood sugars regarding their diabetic patient so they could decrease the risk of this problem. I know from experience, nurses get busy and sometimes often only have a chance to chart right before they leave for the day, so if the previous nurse would have simply stated “I gave patient blah blah in room blah blah her 2 units of regular insulin based on her blood sugar of blah blah at

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0700, I just have not gotten a chance to chart that administration yet.” Lastly, another recommendation would be directed solely to the student nurse and having the student understand, state, and comply to the policies provided through the school and hospital. They are set in place for a reason due to liability and prevention of adverse outcomes.

Cause and Effect (“Fishbone”) Diagram Persons

Method of Delivery

Environment

Performed outside of hospital policy, due to clinical instructor not being present

Clinical Instructor

Assigned Unit Nurse

Student Nurse

Chaotic

Busy

Unit Nurses under pressure to administer medications on time

Act performed out of convenience

Student noticed night shift nurse retroactively charted med admin at 0700 of insulin AFTER SN administered at 0730 Student nurse noted no record of insulin coverage charted prior to med admin time of insulin

Assess for hypoglycemia; interventions included constant monitor and OJ

Although vitals were normal, incident report was completed

Electronic Records

Other Factors

3

Double Dose Given and Improper Documenta tion

4...