Case Study Mr Jeffries, a 76-year-old patient was admitted to the acute aged care ward of a hospital following a fall at home, where he injured both his wrists. He has a history of Type 2 diabetes mellitus and usually self-administers his insulin at home via an insulin pen TDS before meals. The ward was very short-staffed for the morning shift due to staff absences (gastro outbreak), so RN Amanda was seconded from the paediatric ICU (PICU) department to work the morning shift in the acute aged care ward. Amanda had 30 years of PICU experience and had not looked after adults since her graduate year, however, she was happy to help as she thought that working in aged care had to be much easier than nursing critically unwell infants. Amanda introduced herself to Mr Jefferies and he asked her when he was going to get his insulin, so he could eat breakfast. Amanda read the medication order and went to the treatment room to prepare the 2 units of Humulin. She was a bit confused because the medications and equipment were different to the PICU ones, but she drew up the insulin, checking carefully that she had the right patient, right time, and right medication against the medication order. She asked Agency RN George to check the prepared injection, and George glanced at the items in the kidney dish, checked the insulin vial to see that it read “Humulin” and the use-by date and said it was all OK. Amanda proceeded to administer the insulin to Mr Jeffries and then continued with her busy shift. An hour later Mr Jeffries rang the bell as he was feeling very unwell. He appeared anxious, confused, tachycardic and sweating, so Amanda checked his BGL, and it was 1.8 mmol/L. The MET team were called and after some emergency IV dextrose, Mr Jeffries was transferred to HDU for monitoring. An incident form was completed and when questioned by the unit manager about the incident Amanda demonstrated that she had used a 3ml syringe to administer the insulin instead of an insulin syringe. The patient had received 2 MLS (200 units) of insulin instead of the ordered 2 units of insulin. The hospital Quality and Safety unit investigated this incident. Root cause: medication error – incorrect dose of medication administered to the patient. Case study adapted from Staunton, P. and Chiarella, M., 2017. Law for nurses and midwives. 8th Ed. Chatswood, N.S.W.: Elsevier Australia. NRSG378 Extended Clinical Reasoning – Assessment 2 Project Root Cause Analysis (RCA) Report – Template INSTRUCTIONS: Please use this template to complete assessment 2. You will choose from either ONE of two case studies provided to complete a RCA. Your discussion must be cited and supported by a wide range of relevant and credible sources for each question below. There is no need to include an introduction or conclusion. You are required to include a final reference list at the end. A minimum of 15 high quality resources are to be used. All answers must be supported using a variety of high-quality primary evidence. Avoid using any one source repetitively. 1. Discussion of identified root cause Briefly discuss how the identified root cause has led to the outcome for the patient. 150 words 2. Identification and discussion of contributing factors Discuss three (3) contributing factors that have likely led to this sentinel event. 150 words 3. Links to NMBA RN Standards for Practice Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not just standard 7).350 words 4. Links to National Safety and Quality Health Service (NSQHS) Standards Identify and discuss two (2) separate NSQHS Standards which were breached (or not met) in this scenario, that may have led to the identified root cause. You need to identify and discuss specific actions items (e.g. Clinical Governance Standard, action 1.03). 350 words 5. Recommendations Outline three (3) recommendations to address the contributing factors you identified from the chosen case study (from question 2), or the root cause. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations. 600 words Recommendations to address contributing factors or root cause Practical example(s) to achieve recommendations Position responsible/ accountable 1. 2. 3. · Your discussion must be cited and supported by a wide range of relevant and credible sources for each question below. There is no need to include an introduction or conclusion. · You are required to include a final reference list at the end. A minimum of 15 high quality resources are to be used. All answers must be supported using a variety of high-quality primary evidence. Avoid using any one source repetitively. Once you have chosen your case study, you will be required to respond to the following sections: 1. Briefly discuss how the identified root cause has led to the outcome for the patient. 2. Discuss three (3) contributing factors which have likely led to this sentinel event. 3. Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not just standard 7). 4. Identify and discuss two (2) separate National Safety and Quality Health Service (NSQHS) Standards which were breached (or not met) in this scenario, that may have led to the identified root cause. You need to identify and discuss specific actions items (e.g. Clinical Governance Standard, action 1.03). 5. Outline three (3) recommendations to address the contributing factors you identified from the chosen case study (from question 2). These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.
