NUR 409 Module 4 Project One Quality Analysis Example

Project One: Root Cause Analysis of a Delayed Antibiotic Dose After Emergency Department Transfer

[Student Name]

Southern New Hampshire University

NUR 409: Strategies for Quality Improvement in Healthcare

Project One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project One: Root Cause Analysis of a Delayed Antibiotic Dose After Emergency Department Transfer

The performance gap activity showed that about three in ten time-critical first doses on 5 East, a composite medical unit, arrive late after emergency department transfer. Aggregate data show the pattern; a single event shows how the causes combine. This Project One analysis examines one such event using the root cause analysis and action approach known as RCA2, which emphasizes finding system causes and choosing actions strong enough to prevent recurrence (National Patient Safety Foundation, 2015). The analysis finds three root causes, none of them the nurse's attention, and recommends two stronger actions that change the handoff and the medication schedule so the next dose can no longer fall between departments. The patient, staff and figures are composites.

The Event

Mr. H., a composite 64-year-old man with type 2 diabetes, came to the emergency department with cellulitis of the lower leg. At 1:10 p.m., he received his first dose of intravenous cefazolin, ordered every 8 hours, so his next dose was due at 9:10 p.m. The hospital's list of time-critical medications, built from national guidance on timely administration (Institute for Safe Medication Practices, 2011), includes scheduled intravenous antibiotics for active infection, so this dose was expected within 30 minutes of 9:10. He waited for a bed for several hours and arrived on 5 East at 7:40 p.m., during the evening medication pass. The emergency nurse's handoff listed his medications as given but did not include the time of the cefazolin dose. The admitting orders created a new schedule starting at the unit's standard 10:00 p.m. time. At 10:00 p.m., the receiving nurse found that cefazolin was not in the unit's automated dispensing cabinet, because pharmacy had not yet verified the new orders, and paged pharmacy. The dose arrived and was given at 11:55 p.m., 2 hours and 45 minutes after it was due. Mr. H. was not harmed, but his fever persisted overnight, and the delay was reported the next morning.

The Team and Method

The review team included the unit's clinical nurse specialist as facilitator, a staff nurse from 5 East, an emergency department nurse, a pharmacist, an informatics nurse and a patient safety officer. The nurses directly involved were interviewed but were not team members, following RCA2 guidance that reviews should focus on systems and be conducted in a way that does not assign blame. The team built a detailed timeline from the medication record, the dispensing cabinet log and the handoff note, then walked the process on both units during an evening medication pass to see the conditions firsthand.

Contributing Factors

The team grouped contributing factors into a cause-and-effect diagram with six categories. Table 1 summarizes the most important factors.

Table 1

Contributing Factors to the Delayed Cefazolin Dose, by Category

Note. Composite event. Categories follow a standard cause-and-effect (fishbone) structure.

Root Causes

The team asked, for each factor, whether removing it would have prevented or significantly reduced the delay. Three root causes met that test. First, no step in the transfer process requires the last administration time of time-critical medications to travel with the patient; the unit nurse had no reliable way to know the dose was due at 9:10. Second, the order-entry system builds the new schedule from unit standard times rather than from the last documented dose, so the record itself pointed to the wrong time. Third, pharmacy verification and cabinet stocking do not prioritize time-critical first doses, so even a nurse who knew the correct time might not have had the drug. The workload of the medication pass contributed but was not a root cause, because a nurse who knew the dose was due and had the drug available could have delegated or reprioritized.

Actions, Ranked by Strength

RCA2 guidance ranks actions from stronger to weaker, favoring changes to the system, such as forcing functions, standardization and simplification, over weaker actions, such as training, warnings and new policies (National Patient Safety Foundation, 2015). Reviews of real root cause analyses show why this matters. Kellogg et al. (2017) examined 302 analyses from one health system and found that the most common proposed solutions were training, process changes and policy reinforcement, weaker actions less likely to prevent recurrence, and that several event types recurred despite repeated analyses.

The team therefore recommends two stronger actions and one intermediate action. The first, a forcing function, adds a required field to the electronic transfer handoff for the last administration time of each time-critical medication; the handoff cannot be completed without it. The second, a standardization change in order entry, sets the first unit dose of a time-critical medication automatically from the last emergency department administration, with pharmacist review. The intermediate action stocks the ten most common time-critical first doses, including cefazolin, in the unit cabinet with pharmacist-approved override access for first doses. Education about the new process will accompany these changes but is not relied on as the fix.

Measuring the Effect

Each action has a measure. The handoff change will be tracked by the percentage of transfers with last-dose times completed, the scheduling change by the percentage of first time-critical doses scheduled from the last emergency department dose, and the stocking change by the number of first doses delayed because a drug was unavailable. The outcome that ties them together is the unit's lead process measure for timely first doses after transfer, reported weekly on the run chart against the aim of 95% within six months.

Conclusion

Mr. H.'s antibiotic was late because three systems failed together: a handoff that did not carry the dose time, a schedule that pointed to the wrong hour and a supply process that did not treat the first dose as urgent. A root cause analysis that stopped at the busy nurse would have produced a reminder to be careful. By tracing the event to its system causes and choosing stronger actions, this analysis sets up changes that would have protected Mr. H. even on a night when everyone was busy.

References

Institute for Safe Medication Practices. (2011). ISMP acute care guidelines for timely administration of scheduled medications. https://www.ismp.org/sites/default/files/attachments/2018-02/tasm.pdf

Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2017). Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? BMJ Quality & Safety, 26(5), 381-387. https://doi.org/10.1136/bmjqs-2016-005991

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm