A client at your hospital is sent to cardiology for a routine test. The client returns without incident, and you document the time and condition of the client on return to the room. The next day, you are summoned to the unit manager’s office, along with the charge nurse and unit secretary. The manager describes how the client was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for 2 days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manager demands an explanation for 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.

1. Who is responsible for initiating a root cause analysis (RCA)?
2. As the Nurse Leader how would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conducting the RCA?
3. The hospital has a nonpunitive 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?
4. 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 this information, where might the fault lie?
5. Since you are the nurse leader, what possible changes/suggestions could you make to decrease the possibility of a similar incident in your unit?
6. Which Joint Commission patient safety goal was addressed in this case study?
7. One of the process problems identified involved nurses transcribing the computer MAR onto a sheet of paper. The nurse then takes the handwritten paper into the medication dispensing room to remove medications. The computer on wheels is too large to take into the small medication room. What is this an example of?