Nursing Leadership: Root Cause Analysis-Patient Scenario

DATA COLLECTION 

FINDINGS

WHAT ADVERSE EVENT HAPPENED? 

A 62-year-old patient with chronic heart failure on admission received a sedative and an analgesic to relieve her pain and put her to sleep. Later, the patient fell from the bed and broke her left hip. During the surgery to correct the fracture, the patient sufferers a heart attack and passes on. 

WHEN DID THE EVENT HAPPEN? 

The event occurred on the night of admission at 0300hrs.

WHY DID THE EVENT HAPPEN? 

• The calling system was not in use
• The nurse did not perform a patient risk assessment 
• The unit was short-staffed
• The nurse had not completed the orientation
• The room was cluttered
• The room was not adequately prepared for the patient.
• The was no close monitoring of the patient by the nurse since she was alone and had another admission to attend.

HUMAN FACTORS 

Staffing 

Short staffing of nurses in the unit.

Education 

• The patient was not educated on the risk of falling, to call for assistance when in need.
• The nurse had not completed the orientation as necessary

Communication 

• The call light was clipped to the suction outlet. The patient was not informed how to call for assistance.
• The nurse did not ask for assistance or help from the supervisors or nurses in other units.
• The nurse had no hospital orientation.

___ Other(list):

  The nurse had another admission to attend.

EQUIPMENT FACTORS 

Malfunction of equipment 

• The bedside rails did not prevent the patient from falling.
• The call bell was far from the patient

Preventative maintenance not performed 

• The bed and rails may not have been checked for functionality to detect any fault for repair.
• The proximity of the call system to the patient was not assessed

Inappropriate use of equipment 

Two extra chairs and the I.V pump were in the room were not required.

Equipment not available when needed 

The call light was clipped to the suction outlet not available to the patient.

Inadequate controls or alarms on equipment

None was identified in the patient room

:

ENVIRONMENTAL 

FACTORS 

POLICY/PROCEDURE 

Path obstructed 

Two extra chairs, an I.V pump, and the call light were all clipped on the suction outlet.

Area cramped or cluttered 

• The patient’s room had unnecessary equipment or items.
• Area under construction 

Inadequate systems to identify a high-risk area

The nurse who was alone in the unit had many patients to attend, and had not completed the orientation to the hospital received a patient with a high risk of falling and went ahead to receive another admission without giving due attention to the first one.

Inadequate safety procedures 

The nurse had not reviewed the fall policy, safety procedures, and other hospital policies.

Area not meeting code/regulation 

No hospital orientation for the new nurse.

Other (list):

• The nurse did not follow the fall policy and safety procedures.
• The patient communication policy was not followed.
• The equipment management procedure was not followed.
• The hospital orientation procedure and policy were not followed.

OTHER 

• No supervision by the seniors to check on the unit.
• Allocating a new staff on night duty alone.
• No patient monitoring was done.