CASE STUDY:
A 79-year-old patient, Mrs Sergi was admitted to hospital for a routine hip replacement. Mrs
Sergi had been experiencing hip pain for a few years and was alert and oriented before
surgery, although she was noted to be frail and weighing 35kg.
The operation was performed at the start of the afternoon operation list and her surgery
was uneventful. Mrs Sergi had a PIVC inserted in OT and the medications chart recorded
that she had received 500mls of NaCl 0.9% IV intraoperatively. At the conclusion of the
operation the Anaesthetist commenced a new 1L IV bag of NaCl 0.9% and ordered IV NaCl
0.9% over 10 hours x 2 bags (100 ml/hour), until the patient’s review the following day.
Mrs Sergi was transferred to PACU at 3pm into the care of the PACU team and a PACU
observations chart was commenced. Mrs Sergi was soon alert and oriented and
communicating coherently with PACU staff and her observations were all within normal
limits and her pain well controlled. At handover to the ward nurse (Fiona), the PACU nurse
mentioned that the anaesthetist wanted Mrs Sergi to have ‘as much fluid as possible’, so
Fiona wrote this on the observation chart.
On RTW at 4pm Fiona settled Mrs Sergi into the ward and commenced a fluid balance
chart and wrote “as much fluid as possible” in this chart too. She set up the IV pump at
200mls/hr and commenced hourly post-op obs. The ward got busy that evening and only 1
set of observations were recorded in Mrs Sergi’s chart. At handover to night staff at 9.30pm
Fiona reported that Mrs Sergi had “obs within normal limits except for an elevated BP, and
lowish pulse and a bit of a post-op cough, to have as much fluid as possible and her IVT
needs a new bag as charted”.
The Night nurse (Tanya) checked Mrs Sergi’s IVT at 10pm and commenced a new 1L bag
of NaCl 0.9% at 200 ml/hr and noted that the patient was short of breath and confused, so
she recorded this in the patients chart as “confused ?? dementia” and continued with her
shift. At 3am Tanya went to change the IVT bag and noticed that Mrs Sergi was extremely
short of breath and very agitated, so she called the on-call Dr for a non-urgent review. The
Doctor came to the ward at 4am and found Mrs Sergi unresponsive. A MET call was
initiated but Mrs Sergi could not be revived and was declared deceased at 4.30am.
Scenario adapted from Staunton, P. and Chiarella, M., 2012. Law for nurses and midwives.
Chatswood, N.S.W.: Elsevier Australia.
Root Cause Analysis Report – Template
INSTRUCTIONS:
Please use this template to complete assessment 2. You are required to respond to only ONE of the provided case studies. You need to indicate which case study you have chosen in the first section.
Your discussion must be cited and supported by a wide range of relevant and credible sources for each section. You are required to include a final reference list at the end.
1. Description
Identify which case study you have chosen (1 or 2), and provide a brief description of the event and the outcome for the patient.
2. Identification of root cause and contributing factors
Identify one (1) root cause and discuss at least three (3) contributing factors which have likely caused this sentinel event.
3. Links to NMBA RN Standards for Practice – https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspxhttps://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
Identify and discuss at least two (2) NMBA RN Standards which were not practiced or maintained by the nurses involved in this sentinel event, that may have led to the identified root causes.
4. Links to National Safety and Quality Health Service (NSQHS) Standards – https://www.safetyandquality.gov.au/standards/nsqhs-standardshttps://www.safetyandquality.gov.au/standards/nsqhs-standards
Identify and discuss at least two (2) NSQHS Standards which were breached (or not met) by this health organisation, that may have led to the identified root causes.
5. Recommendations
Outline a minimum of three (3) recommendations to address the root causes identified from the chosen case study. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.
(NOTE: you can add more rows if required – right click on the last row of the table, “insert”, “insert row below”)
– Table headings:
1. Recommendations to address root cause
2. Practical example(s) to achieve recommendations
3. Position responsible/ accountable
6. APA 7th Referencing