NUR 659 Module 3 Milestone One Example

Milestone One: A Root Cause Analysis of an Insulin Wrong-Patient Event With Strong Corrective Actions

[Student Name]

Southern New Hampshire University

NUR 659: Healthcare Safety, Just Culture, and Regulation

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: A Root Cause Analysis of an Insulin Wrong-Patient Event With Strong Corrective Actions

Root cause analysis is the most common method hospitals use to investigate serious events, and it is often disappointing. Teams meet, identify causes and produce recommendations that amount to retraining staff or reminding them of existing policies, and similar events recur. In the composite Westbrook hospital, insulin meant for one patient reached another after a night nurse typed in identifiers by hand because the scanner would not read; the recipient became severely hypoglycemic before being treated. The Module Two systems analysis identified latent conditions behind the error. This milestone documents the formal root cause analysis. It argues that following a structured method and deliberately choosing actions high in the hierarchy of effectiveness can turn an investigation into lasting change.

Why Many Analyses Fail

Wu et al. (2008) argued that root cause analysis in medicine, although widely required, had little evidence of effectiveness, that it was often done inconsistently and without sufficient expertise and that its recommendations were frequently not implemented or evaluated. Kellogg et al. (2017) reviewed eight years of root cause analyses at an academic medical center and found that the most frequent solutions were training, process changes and reinforcement of existing policies, while strong solutions were uncommon; events of the same types recurred during the period studied. Both papers suggest that the problem is less the idea of investigating events than the way investigations are conducted and the weakness of the actions they produce.

The RCA2 Method

In response to these problems, the National Patient Safety Foundation (2015) published RCA2, which stands for root cause analysis and action. It recommends prioritizing events by risk, forming a small team of four to six people with expertise in the process involved and including someone outside the unit, completing the analysis within 45 days, interviewing involved staff in a nonpunitive way, writing causal statements that link causes to effects and, most importantly, choosing actions from a hierarchy that ranks forcing functions, architectural changes, simplification and standardization as stronger than checklists and software alerts, and those in turn stronger than training, warnings and new policies. It calls for each action to have an owner, a deadline and a measure, and for leadership to review and fund the action plan.

Westbrook's team included a pharmacist, a clinical informatics nurse, a biomedical engineer, a night-shift nurse from another medical unit and the patient safety officer as facilitator. The nurse involved and the charge nurse were interviewed separately, and the team observed medication administration on three night shifts.

Causal Statements

The team wrote causal statements in the form RCA2 recommends, describing how a cause led to the event. Frequent barcode scanner failures, combined with an electronic record that accepted manual identifier entry without any additional verification, led nurses to bypass scanning routinely, which removed the defense designed to catch wrong-patient errors. The absence of an alert or visual flag for patients with similar names on the same unit increased the likelihood that the nurse would confuse the two patients. Staffing one nurse below the unit's standard increased workload during a peak medication period, which increased the likelihood of rushed patient identification. The lack of a same-shift process for reporting and repairing scanner failures meant that equipment problems persisted for days and workarounds became normal.

Action Plan

Table 1 shows the action plan. The two strongest actions address the most important defense, barcode verification, by making it reliable and by preventing it from being bypassed silently. Training was retained only as support, not as a primary fix.

Table 1. Causes, Corrective Actions, Strength and Measures

Note. Training on patient identification was included as a supporting measure but deliberately not listed as a primary action, since weaker actions alone rarely prevent recurrence.

Leadership Review and Feedback

The team took its plan to the hospital's senior executives, who approved the budget for replacement scanners and the informatics work. RCA2 emphasizes that leadership support is itself a strong action, since it signals that safety is a priority and provides resources. Findings were shared with the involved nurse, who contributed to the analysis, and summarized for all medical unit staff without names, including what would change and when, so that staff could see that reporting leads to action.

Evaluation

Each measure will be tracked monthly for a year. The primary outcome is wrong-patient medication events, detected through incident reports and a monthly trigger review of charts with rescue medications such as dextrose and naloxone. Process measures include the proportion of medication administrations scanned, the manual override rate and scanner downtime. If manual overrides remain high after the hard stop, the team will investigate whether new workarounds have emerged.

The team also considered actions it rejected. A proposal to require a second nurse to witness every insulin dose was set aside because it would add a weak, easily skipped double check to every administration without addressing the scanner failures, and a proposal to discipline staff who bypass scanning was rejected because it would punish a workaround the system had created. Documenting rejected options shows reviewers that the team weighed alternatives rather than defaulting to familiar responses.

Conclusion

The insulin event could easily have ended with retraining and a written warning, the kind of weak response that research shows allows events to recur. Following RCA2, with an independent team, causal statements and an action plan led by a forcing function and reliable equipment, each with an owner and a measure, gives Westbrook a realistic chance of preventing the next wrong-patient error.

References

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. National Patient Safety Foundation.

Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685-687. https://doi.org/10.1001/jama.299.6.685