Author Question: A client's surgical wound dehisced when a nurse mistakenly removed the staples before this had been ... (Read 107 times)

genevieve1028 · **on:** Jul 22, 2018

A client's surgical wound dehisced when a nurse mistakenly removed the staples before this had been ordered.

The nurse is distraught, and acknowledges that she forgot to check the client's orders and assumed the client was on a later postoperative day than he actually was. Following root cause analysis, which organizational response is appropriate? Select all that apply.
A) The nurse's actions will be categorized as being intentionally reckless.
B) The nurse will be found to have committed a human error.
C) Systems around the documentation of orders will be reviewed.
D) The nurse will be disciplined by an impartial review board.
E) The nurse's at-risk behavior will be weighed according to standards of practice.

Question 2

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked.

When performing root cause analysis in order to identify the essential cause of this error, what question should first be asked?
A) Has this, or something very similar, ever happened on the unit before?
B) Why did the second nurse administer this drug to the client?
C) What could the two nurses have done to ensure this didn't happen?
D) What were the possible adverse outcomes that could have resulted from this error?

dajones82 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

Ans: B, C
Feedback:
The nurse's action will likely be categorized as a human error. There is no evidence of malice (intentional recklessness) or failing to appreciate the gravity of an action (at risk behavior). As such, discipline is an unlikely response. As with any error, systemic factors must be examined.

Answer to Question 2

Ans: B
Feedback:
Asking why is essential to the process of root cause analysis. Asking a series of why questions can reveal underlying causes. Each of the other listed questions addresses a valid aspect of the event, but none address the underlying causes, which is the focus of root cause analysis.