Discussion 5

For this discussion forum, your initial posting  will be a root cause analysis (RCA) that includes an overview of the sentinel event, a fishbone diagram, and the five Why’s associated with one of your possible root causes in the fishbone diagram. Your RCA will be based on one of the scenarios provided under “Materials,” “Course Assignments.”  In your discussion group, please ensure that both scenarios are analyzed.

In this discussion, you will propose a solution to one of the possible root causes discovered in your fishbone diagram. Provide an in depth discussion of your proposed solution to the quality/safety issue using the PDSA/PDCA process.  Be specific about what you would recommend to the organization to prevent the sentinel event from happening again in the future.   

Provide feedback to two others regarding their root cause identification.  Did all of you identify the same root cause?  Why or why not?



NURS 420 Informatics, Quality, and Safety for RNs

Instructions: Review the Case Scenarios posted under “Course Content.” Also review the QI document by Health Quality Ontario posted under “Additional Course Readings.” Write a response using the following rubric as your guide to content required.

Criteria for Informatics, Safety, and Quality Research Paper


Introduction and Background: Select one of the scenarios in which a medical error(s) occurred. The scenarios are listed under “Content.” For the selected scenario, identify the problem and
the significance of the issue in nursing and health care. Provide
background information on the scenario, and
explain the purpose of a
Root Cause Analysis

Fishbone Diagram: Develop a fishbone diagram that addresses the defects or problems you identified in the case scenario. You are expected to post a fishbone diagram that shows the defects by category as a part of the initial posting. Then, discuss the following: What might be the problems that led to the error? What are five why questions that you might ask to get more information related to the incident? Identify what you determine to be the top cause of the error.

Select one of the possible causes identified in the fishbone diagram. Write a 5 Whys for this cause.You do not need to select the identified root cause of the sentinel event. The 5 Whys can be written on any of the possible causes identified in the case scenario.

Summary: Tie together the sections of the posting. Include the major
findings and
conclusions drawn from the exercise.

Review your work to ensure that the APA format is correct and the posting is free of spelling and grammatical errors.

The patient was a 67-year-old male who underwent a right total knee replacement. Following the procedure, the patient was treated in the post-anesthesia care unit where an epidural catheter was inserted for postoperative pain

management. Following one episode of hypotension, which was treated successfully with ephedrine, the patient was discharged to an inpatient medical-surgical care nursing unit with the epidural in place.

Although the nurse assigned on the medical-surgical unit customarily worked on the postacute critical care unit, she had been reassigned to the medical-surgical nursing care unit. The nurse stated that she understood her assignment at the time of the patient’s admission to this unit was to provide oversight of the patient care on the entire floor for that shift. The nurse assessed the patient upon his admission to the unit and found him to be stable. The nurse understood that the direct care of the patient was assigned to a licensed practical nurse (LPN). Ordered vital signs and checks of the xyphoid process were not documented.

Approximately 3 hours after arriving on the unit, the patient was unable to tolerate ordered respiratory therapy due to nausea and vomited shortly thereafter. According to the nurse, approximately 10 minutes after the episode of vomiting, the LPN found the patient cyanotic and unresponsive and immediately called a code.

The nurse responded, as did the code team, and the patient was intubated and transferred to ICU. This account of events was disputed by the LPN and two other staff on the unit who understood that the nurse was responsible for the direct care of the patient. The LPN stated that it was the nurse who found the patient to be unresponsive at some point after the episode of vomiting and called the code herself. The elapsed time between the episode of vomiting and the code is also disputed.

The eventual diagnosis was anoxic encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was withdrawn. The patient breathed independently and was transferred to hospice care where he subsequently expired.

Carla is a 29-year-old woman with renal failure from polycystic kidney disorder, a congenital disease that requires her to undergo frequent dialysis. For several years, she has lived in a suburb of a medium-sized city in the American southwest. Carla is single and works part-time at a small printing company. Her boss offers her the flexibility to get to her dialysis appointments — which last three hours if the center is running on time — but the time away from work is a strain for Carla and for her boss. 

It isn’t easy for Carla to get to her dialysis appointments three times a week. She recently had to give up her car because she could no longer afford car payments and insurance, so she now relies on buses and cabs to get to the dialysis center. Carla’s mother lives nearby and is a major source of emotional support; she gives Carla rides if she’s able to get time off work, but that is rarely possible. Carla has a few close friends who provide her with a strong social network, but because Carla’s appointments take so long and happen during business hours on weekdays, she usually has to go by herself.

Day One, Monday 

In her arm Carla has an arteriovenous fistula, a surgically created connection between an artery and a vein, for hemodialysis. One Monday during dialysis at her usual outpatient dialysis center (a private center in a large chain of dialysis units throughout the area), the technician notes poor blood flow through the catheter. With poor flow, it is difficult, if not impossible, to complete an effective dialysis session. Because of the poor flow, it takes five hours to complete the dialysis that day, instead of the usual three. The nephrologist, Jesse, orders an ultrasound of Carla’s upper arm, to be done at the local hospital about eight miles away. The nurse, Mercedes, gives Carla a handwritten order form for the ultrasound and calls the radiology department, scheduling the test for 9 AM the next morning. 

Carla is too embarrassed to tell Mercedes that she no longer has a car and may not be able to get to the test on time.

Day Two, Tuesday 

Carla takes three buses in the morning, only to arrive at the hospital at 9:30 AM due to the complex bus schedule. When she checks in at the desk, the clerk, Jonas, tells her they cannot perform the test. He says the department has a policy that anyone who is more than 15 minutes late must be rescheduled. The department has a high percentage of patients who show up late or not at all, he says, and they want to be fair to those who arrive on time. Carla asks if there is any way to get the test done today, but Jonas, who got yelled at last week for sneaking in a late patient, tells her this is simply not possible. He reschedules the test for Thursday at 10 AM. Upset, frustrated, and exhausted by the fact that she just wasted several hours, Carla goes home. 

Day Three, Wednesday

Wednesday morning Carla goes to dial


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