Reference no: EM133866362

CASE STUDY:

A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident, and you document the time and condition of the patient on return to the room. The next day you are summoned to the unit manager's office, along with the charge nurse and the unit secretary. The manager describes how the patient was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for two days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manger demands an explanation of the incident because controls are in place because of similar incidents on the unit that should flag the medication, requiring the nurse to hold the medication prior to the test.

A. Who is responsible for initiating a root cause analysis (RCA)?

B. How would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conductiong the RCA?

C. The hospital has a non-punitive policy for mistakes and errors. How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?

D. The investigation reveals that there were 12 admits and discharges occurring around the time of the incident, with only one unit secretary. Of the admissions, 10 were attributed to the same physician who ordered the test. The nurse was admitting a complicated patient with multiple needs when the patient left for the procedure. Based on the information, where might the fault lie?