Question

A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident, and you document the time and condition of the patient on return to the room. The next day, you are summoned to the unit manager's office, along with the charge nurse and unit secretary. The manager describes how the patient was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for 2 days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manager demands an explanation for the incident because controls are in place because of similar incidents on the unit that should flag the medication, requiring the nurse to hold the medication prior to the test.

A. Who is responsible for initiating a root cause analysis (RCA)?

B. How would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conducting the RCA?

C. The hospital has a nonpunitive policy for mistakes and errors. How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?

D. The investigation reveals that there were 12 admits and discharges occurring around the time of the incident, with only one unit secretary. Of the admissions, 10 were attributed to the same physician who ordered the test. The nurse was admitting a complicated patient with multiple needs when the patient left for the procedure. Based on this information, where might the fault lie?

E. What possible suggestions could you make to decrease the possibility of a similar incident?

F. How did the unit use failure mode and effects analysis?

G. Which TJC patient safety goal was addressed in this case study?

H. One of the process problems identified involved nurses transcribing the computer MAR onto a sheet of paper. The nurse then takes the handwritten paper into the medication dispensing room to remove medications. The computer on wheels is too large to take into the small medication room. What is this an example of?

Answer 1

A. Unit Manager is responsible to initiate RCA.

B. Root cause analysis to be split up into following:

Man.

Machine.

Materials.

methods.

We will include the staff nurse , Unit secretary, unit manager, IT team, MR team, test team.

Purpose of the RCA is to identify the cause of the error by listing down the possible gaps that had led to the error in all the Cross functional areas. Superficially this error lies at unit secretary level but if we dig deeper we will come to know many underlying gaps which led to this error. we should not only target or train unit secretary but to remove the deep lying root cause such as providing handy mobiles or tablets which can be used while delivering medicines as per physician orders. Also man power mapping to be done to assign tasks as per the optimal load to a single unit secretary. RCA will not limit to them but also covers the test personnel to ensure that phtsician order to stop Glucophage for 2 days and perform the test.

C. Since the hospital has non punitive policy RCA will be done without any bias on the unit secretary. Fear will not be present in the employees to an extent to hide critical processes.

D. The root cause lie in the overloading of the unit secretary with 12 patients admisdions and 12 patients discharges same at a time. Along with one more critical patient admission and 1 test given. All the 10 patients admitted have been assigned to the same physician. Man power management is not efficient which had led to this error. Hospital Management or HR to cirrect this work overload and also different task to be assigned to different personnel.