Running head: ROOT CAUSE ANALYSIS 1

Root Cause Analysis

Rebecca Ramirez

Grand Canyon University: NSG 436

03/01/2020
ROOT CAUSE ANALYSIS 2

Root Cause Analysis

    Root cause analysis is an intricate process that calls for multiple parties to come

together to identify the main issue at hand (Charles, et al., 2016). This process also provides

standard methods of prevention in situational predicaments or recurring events. The following

information provided will be explaining the individuals involved, the events leading to the exact

problem and other factors playing into the assigned root cause analysis. 

Summary

            The problem presented in this root cause analysis scenario is based off the incorrect

additional dose of insulin administered to a patient on the floor. As the day shift nurse was

making her rounds, she immediately saw the scheduled time for insulin at 0600 was not given by

the night shift nurse. Knowing this information, she starts to prepare the medication to be

administered. The student nurse that was assigned with the day shift nurse that day mentioned

that the clinical instructor must be present prior to the medication being administered. This is to

ensure that the drug, dosage, patient, time, route, and documentation is correct upon

administering to the patient. The student nurse was still instructed to administer the insulin due to

the fact that the medication was already past the correct time of administration. With the

supervision of the nurse on shift, the student went ahead and gave the dose of insulin to the

patient at 0730. The student nurse continued then to electronically document the administration

of insulin. Upon charting, she quickly noticed that the night shift nurse retroactively charted the

medication administration of insulin for 0700, signifying that two doses of the scheduled insulin

rather than just the one. 

Team Members Involved

            There are several members who play a part in a root cause analysis. One of the most

important members of the root cause analysis is the risk management team. Risk management

provides internal investigation and concludes whether or not the hospital will self-report to

outside regulatory agencies. The physician assigned to the case is another vital member of the

root cause analysis team, in which they provide information on the patient’s health, history, and

current status. This allows further investigation to identify the cause or root of the problem. The

department of social work also works closely with the root cause analysis team in organizing the

case coordination of the patient’s stay at the hospital. The benefits of bringing in a director onto

the root cause analysis team would be that they have insight and experience in overseeing the

nurses of all departments. The director would be able to help implement the appropriate

corrective actions, if needed. The members mentioned above would make a great impact in

investigating the case along with implementing corrective actions. 

Recommendations for Proposed Actions

One of many recommendations that can be made is initiate insulin protocols. This would

mean that during shift report, if a patient is getting insulin, the nurse on shift is mandated to

include what the last blood glucose was and what time the last insulin was given. In addition,

another nurse should be present for the handoff. This would involve two nurses hearing and

overseeing shift report on a diabetic patient, so that two people are responsible for ensuring

correct insulin administration and overall patient safety. Another recommendation for corrective

action in this scenario, would be for nurses to document before leaving the patient’s room

alongside another nurse in the room. This would require the nurse to bring the web on wheels

into the room with an additional nurse being there to ensure that the correct insulin and dosage

was administered. 
ROOT CAUSE ANALYSIS 4

Conclusion

            Root cause analysis is a very important process that helps with the prevention of errors

that are made on a nursing floor, leading to the well-being and safety of patients in hospitals

around the world. As health care professionals, patient safety and patient satisfaction is our

biggest priority. Root cause analysis helps future nurses, doctors, certified nursing assistants, and

more to provide the best care possible without harming patients.

References

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Ying Li, Caird, M. S., Biermann, J. S.,

& Hake, M. E. (2016). How to perform a root cause analysis for workup and future

prevention of medical errors: a review. Patient Safety in Surgery, 10, 1–5. https://doi-

org.lopes.idm.oclc.org/10.1186/s13037-016-0107-8