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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 out
eak), 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
eakfast. 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 transfe
ed 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 e
or – inco
ect 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
esources 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 o
maintained by the nurse(s) involved in this sentinel event, that may have led to the identified
oot cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not
just standard XXXXXXXXXXwords
4. Links to National Safety and Quality Health Service (NSQHS) Standards
Identify and discuss two (2) separate NSQHS Standards which were
eached (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 XXXXXXXXXXwords
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
eached (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.
Answered 1 days After Apr 17, 2024

Solution

Dipali answered on Apr 18 2024
6 Votes
WRITTEN ASSIGNMENT        2
WRITTEN ASSIGNMENT
Table of contents
Root Cause Analysis (RCA) Report    3
Discussion of identified root cause    3
Identification and discussion of contributing factors    3
Links to NMBA RN Standards for Practice    4
Links to National Safety and Quality Health Service (NSQHS) Standards    5
Recommendations    7
Implement Comprehensive Staff Training and Orientation Programs    7
Address Staff Shortages Through Contingency Planning: Practical Example    8
Implement Robust Double-Check Protocols for Medication Administration    8
References    10
Root Cause Analysis (RCA) Report
Discussion of identified root cause
The administration of an improper dosage of insulin is the pharmaceutical mistake that was found to be the primary cause of the event involving Mr. Jeffries. The reason for this blunder was that Mr. Jeffries was given 200 units of insulin instead of the recommended 2 units because the wrong 3 millilitre syringe was used in place of the necessary insulin syringe. After one hour of treatment, Mr. Jeffries had acute hypoglycemia due to the underlying cause, with his blood glucose level falling to 1.8 mmol/L. Mr. Jeffries' blood glucose levels dropped significantly, causing him to exhibit symptoms of anxiety, bewilderment, tachycardia, and sweating. As a result, he needed emergency care and was sent to the High Dependency Unit (HDU) for supervision and treatment. Thus, the underlying cause had a direct impact on a sentinel occu
ence that had serious consequences for the security and welfare of the patients.
Identification and discussion of contributing factors
a. Inadequate Staff Training and Experience
One major contributing factor to the mistake was the transfer of RN Amanda from the acute elderly care ward to the Paediatric Intensive Care Unit (PICU) because of staffing shortages. Amanda had worked in PICUs for a long time, but she had not recently handled adult patients or adult drug management. Her uncertainty when preparing and giving the insulin dose was probably caused by her lack of experience with adult care facilities and equipment, which resulted in the mishap (Choudhury & Asan, 2020).
. Staff Shortage and High Workload:
Amanda and the other nursing staff members were under more strain and effort because of the personnel shortage
ought on by a gastro out
eak. Nurses may feel pressured and ove
urdened in such a high-stress setting, which raises the risk of mistakes. It is possible that Amanda's hectic shift made it difficult for her to concentrate enough on preparing and administering her medications, which is why she used the wrong syringe to administer insulin.
c. Lack of Double-Check Protocol
One reason the mistake went undiscovered was that the ward did not have a strong double-check procedure for administering medications. Despite Amanda's request for confirmation, Agency RN George seemed to do a superficial inspection, taking a quick look at the drug without going over the dosage or verifying that the equipment was being used co
ectly. The delivery of the e
oneous insulin dose would have been avoided with a better organised double-check procedure that involved independent confirmation by two nurses.
Links to NMBA RN Standards for Practice
1. NMBA RN Standard 4.1
The need of continuing education and professional development for sustaining nursing practice excellence is emphasised in Standard 4.1. One example of a departure from this norm occurs in the case study when RN Amanda moves from the Paediatric Intensive Care Unit (PICU) to the acute elderly care unit without proper training or orientation. Amanda made mistakes when administering medications since her vast PICU expertise did not sufficiently prepare her for the intricacies of adult care settings. The development and implementation of organised training and orientation programs for nurses transfe
ing across departments or specialisations is...
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