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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 includ

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Home » Uncategorized » 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 includ

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.

The root cause identified in the present case study is a medication error that resulted in the incorrect dose of insulin administration to the patient (Nanji et.al., 2016). Specifically, the error occurred due to the use of a 3ml syringe instead of the appropriate insulin syringe (American Diabetes Association, 2018). This deviation from the standard practice resulted in receiving a higher dose than the prescribed dosage to the patient.
This medicine mistake had serious ramifications for Mr. Jeffries, as proven by his introducing side effects of anxiety, confusion, tachycardia, sweating, and a dangerously low blood glucose level of 1.8 mmol/L (Herring & Jones,2014). Hypoglycaemia, brought about by the excess of insulin, represented a serious gamble to his wellbeing and required earnest intercession by the MET group. The requirement for emergency IV dextrose and ensuing exchange to the High Reliance Unit (HDU) for checking highlighted the weightiness of the circumstance.
Hypoglycaemia can prompt different inconveniences, going from gentle side effects, for example, insecurity and disarray to additional serious results like seizures, loss of awareness, and even passing on the off chance that left untreated or not quickly tended to. Hence, the erroneous organization of insulin because of the main driver of utilizing some unacceptable needle fundamentally imperilled Mr. Jeffries’ prosperity and expected quick clinical consideration regarding balance out his condition. Intime treatment will help to minimize the symptoms and improve the health of the patient
In Mr. Jeffries’ case, mistake in the administration of insulin using the wrong syringe resulted in the well-being of the patient. The requirement for earnest intercession by the Health-related Crisis Group (MET), including the organization of IV dextrose and move to the High Reliance Unit (HDU) for checking, highlights the seriousness of the circumstance.
The result for the patient might have been a lot of more regrettable on the off chance that the hypoglycaemia had not been quickly perceived and treated. Hence, it is very important to adhere to the established medical administration standards.
2. Identification and discussion of contributing factors
Discuss three (3) contributing factors which have likely led to this sentinel event.

The three main factors that has contributed for the health detoriation are as follows:
1. Staff Shortage and Staffing Mix-Up:
The acute aged care ward was grappling with a staffing shortfall due to a gastroenteritis outbreak, necessitating a nurse from a disparate department, the Paediatric Intensive Care Unit (PICU), to fulfil duties on the ward. Although Nurse Amanda from the PICU possessed extensive experience, her recent lack of exposure to caring for adult patients within an aged care milieu likely engendered the error (Szymczak et al., 2020). The Nursing practices will vary between the PICU and aged care settings in terms of demographics, medication and the procedures of treatment. This abrupt transition of unfamiliar standards may cause medication errors that will result in patient health deterioration.
2.Lack of Familiarity with Equipment and Procedures:
Nurse Amanda, notwithstanding her tenure in the PICU, grappled with unfamiliarity regarding the medications and equipment employed in the acute aged care ward. The shift to an alternative clinical environment engendered unfamiliarity with medication administration protocols, including the utilization of insulin syringes. This unfamiliarity purportedly precipitated confusion during the preparation and administration of insulin, culminating in the inadvertent use of an erroneous syringe and the subsequent administration of an insulin overdose to the patient (Biron et al., 2017).
3. Breakdown in Double-Checking Procedures:
Despite Nurse Amanda’s endeavor to enlist the assistance of Agency RN George in verifying the prepared insulin injection, a breakdown in the double-checking process ensued. George, plausibly also unfamiliar with the aged care ward’s protocols and equipment, ostensibly conducted a perfunctory scrutiny of the items in the kidney dish sans comprehensive validation of the dosage and medication vis-à-vis the prescription. This lapse in the double-checking process precluded the identification of the error prior to the insulin’s administration to the patient, emblematic of a…

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