Root Cause Analysis Examples in Nursing

Root cause analysis (RCA) is a structured process used in nursing and healthcare to identify the underlying causes of adverse events, errors, or near misses. By understanding the root causes, healthcare organizations can implement corrective actions to prevent similar incidents from occurring in the future. Here are some examples of root cause analysis in nursing:

Root Cause Analysis Examples in Nursing

1. Medication Error: Scenario: A patient receives the wrong medication dose and experiences an adverse reaction. Root Causes: Inadequate labelling of medications, look-alike/sound-alike drug names, lack of double-checking procedures, and understaffing, leading to rushed tasks. Corrective Actions: Implement clear medication labelling, use barcoding technology, implement a two-nurse verification process, and provide ongoing staff education.
2. Patient Fall: Scenario: A patient falls in the hospital and sustains a minor injury. Root Causes: Inadequate patient assessment, lack of fall risk assessment, slippery floors, insufficient lighting, inadequate patient monitoring. Corrective Actions: Conduct thorough patient assessments, implement fall risk assessments, improve environmental safety (flooring, lighting), increase patient monitoring, and educate staff on fall prevention.
3. Surgical Site Infection: Scenario: A patient develops a surgical site infection after surgery. Root Causes: Improper surgical site preparation, inadequate equipment sterilisation, poor hand hygiene, and lack of adherence to aseptic techniques. Corrective Actions: Implement proper surgical site preparation protocols, ensure proper equipment sterilisation, reinforce hand hygiene practices, and provide staff training on aseptic techniques.
4. Delayed Diagnosis: Scenario: A patient’s medical condition is not diagnosed promptly, leading to worsened outcomes. Root Causes: Inadequate communication between healthcare providers, lack of follow-up on diagnostic test results, incomplete medical history. Corrective Actions: Improve communication among healthcare providers, establish clear protocols for test result follow-up, and ensure comprehensive patient medical history is obtained.
5. Communication Breakdown: Scenario: Miscommunication between nursing shifts leads to missed medications and treatments. Root Causes: Lack of standardized communication processes, inadequate handover procedures, and understaffing causing time pressures. Corrective Actions: Implement standardized handover protocols, use communication tools (e.g., SBAR), and ensure adequate staffing levels to prevent time pressures.
6. Pressure Ulcer Development: Scenario: A patient develops a pressure ulcer during their hospital stay. Root Causes: Inadequate turning and repositioning of the patient, inadequate skin assessment, lack of pressure-relieving devices. Corrective Actions: Implement regular turning and repositioning schedules, conduct thorough skin assessments, use appropriate pressure-relieving devices, and educate staff on skin care.
7. Misinterpretation of Orders: Scenario: Healthcare providers misinterpret a physician’s medication order, leading to incorrect administration. Root Causes: Illegible handwriting, lack of clear medication orders, confusion between similar drug names. Corrective Actions: Encourage electronic prescribing, improve clarity of medication orders, use standardized drug name abbreviations, and provide education on medication administration.
8. Maternal-Infant Safety Issue: Scenario: A maternal-infant unit experiences near misses related to newborn identification. Root Causes: Inadequate patient identification procedures, lack of standardized protocols for newborn identification, busy and chaotic environment. Corrective Actions: Implement standardized newborn identification procedures, use identification bands, and provide staff training on patient identification protocols.

Root cause analysis is a valuable tool in nursing for identifying system-level issues that contribute to adverse events or errors. By addressing these root causes, healthcare organizations can implement effective solutions to improve patient safety, enhance the quality of care, and prevent similar incidents.