You will identify a problem, real or hypothetical, that relates to nursing practice, patient care, or the healthcare environment

NURS 2950 – Scholarly Paper

Root Cause Analysis Paper – Part 1:  Identify the Problem you want to analyze (2 points).

The focus of the scholarly paper is “root cause analysis.”  You will identify a problem, real or hypothetical, that relates to nursing practice, patient care, or the healthcare environment. Complete this worksheet and place it in the assignment folder for Part 1 of the assignment. See the course calendar or assignment folder for the due date.

 

1. Briefly identify the nature of the problem you are planning to discuss.
   1. For example: medication error; patient falls incidents, etc.  This problem can be real from your own experiences, something you observed, an issue described in an article or news event, or a hypothetical problem.

 

The basic topic I’d like to address is related to patient flow. Patient flow issues affect all areas of hospitals and I’ve observed specific problems with patients transferring to a unit without available or proper staffing.

 

2. List the people involved in the issue.
   1. For example, RN #1; 80 yo female patient; patient’s son, etc.

 

PACU nurse

Patient

ICU Nurse

ICU Charge Nurse

Possibly the HUC

House Supervisor

 

3. Describe the details of the situation you will be analyzing. Supply as much detail as you are able.

 

A patient had completed recovery in PACU and was awaiting transfer to the ICU. The ICU had to call in a nurse to accept this patient, who was originally supposed to transfer to M/S. So there was a delay in transfer. This was not clearly communicated across the PACU team and the patient was brought to the unit without a nurse to accept the patient, report had not been given, etc.

The PACU nurse was required to stay with the patient for obersvation until the oncoming nurse arrived.