Running head: HIGH RISK INFUSIONS 1

Root Cause Analysis:

High Risk Infusions

Bon Secours Memorial College of Nursing

NUR 3241

Savanna Hartbarger

Honor Code: “I pledge”

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Root Cause Analysis: Situation

The emergency department is a unique environment of controlled chaos. On this

particular day, a nurse with one year experience in an urgent care who was recently added to the

schedule of the night shift in the ED. The general requirement for ED orientation was four

months, but this nurse had been taken off orientation early due to minimal staffing in the ED.

Shortly after the nurse arrived on shift, she was assigned to hold or admitted patients in the ED.

She noted that one of her patients had a heparin drip ordered which was a drip that she has never

administered during orientation. The nurse pulled the heparin bolus and drip from the Pyxis.

She asked coworkers to sign off on the bolus and drip with her, but all the coworkers

were busy with their own patients. Other nurses were new graduates and were uncomfortable

with heparin drips. One coworker offered to sign off on the heparin if she brought the rolled

computer to one of her patients’ rooms. The new nurse was concerned because her coworker

could not verify the heparin, but was willing to sign off on it without verification. The coworker

assured her that this was commonplace in the ED when acuity was high and the ED was

minimally staffed.

The nurse administered the heparin bolus and started the heparin drip on her patient after

programming of the smart pump. The charge nurse notified this nurse that her patient had a bed

assignment on the telemetry floor. The new nurse called report and transported her patient to the

floor. Upon transferring her patient to the stretcher, she noted that the IV bag was empty. The

heparin was supposed to infuse over several hours, but instead had infused from the short period

of time from initiation to transfer to the floor. The receiving nurse noted the error as well and

suggested that she notify her supervisor.

Background
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In this situation, this nurse had minimal critical care experience and was not allowed to

complete the appropriate length of orientation. She ignored policies and procedures for

medications that required dual verification from two registered nurses (Antonow, & Silver,

2000). She felt unsupported by staff members who either ignored safety measures or who were

new graduates or nurses with minimal critical care experience. She programmed the smart pump

inappropriately and ended up causing the medication error by infusing the heparin at a much

faster rate than it was intended. Unfortunately, this places the patient at higher risk for bleeding

tendencies and other unfortunate side effects.

Assessment: Contributing Factors

The factors that contributed to this medication error included lack of nursing experience,

lack of critical care experience, lack of support from a charge nurse and coworkers, and

overriding safety measures (Feng, Bobay, & Weiss, 2008). Another factor that contributed to this

error was that leadership did not honor her orientation period where she could have honed her

critical thinking skills, assessment skills, and knowledge of high risk medications. In addition,

this nurse likely did not have shifts in the ED where she was assigned to admitted patients.

Heparin drips are not common in the ED, unless they are ordered for admitted patients who stay

in the ED overnight. Last, it is evident that the team as a whole did not follow policies and

procedures to ensure that safety was fostered at the highest standard in all of their patients

(Montesi & Lechi, 2009).

Recommendations and The Role of the Nurse

The first recommendation is to create an orientation checklist that should be signed off by

the preceptee and preceptor, including content such as critical care drips, high risk infusions, and

care of admitted hold patients in the ED. The second recommendation is to allow the nurse to
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complete a full orientation period, regardless of staffing issues. The gaps in staffing could be

filled with experienced ED travel nurses or critical care float pool nurses. The third

recommendation is to eliminate wheeled computers in the ED or create an environment that

encourages honesty in the ED to encourage policy compliance (Montesi & Lechi, 2009). The

fourth recommendation is to ensure that there is an appropriate ratio of new graduate nurses to

experienced nurses in order to encourage competence and favorable learning experiences. The

fifth recommendation is to create smart pump technology or to at least research smart pump

technology that requires the sign-in code of two registered nurses. The sixth recommendation is

to hold mandatory education courses such as in-services where nurses can become competent in

heparin drips and other treatments.

The role of the nurse in this case is to report the medication error and realize that the

patient’s safety was compromised (Antonow & Silver, 2000). She should report the error to her

supervisor and also to a system such as Quantros that encourages reporting. The nurse should ask

for additional training or to extend her orientation period so she could develop competency in

skills or medications that she is unfamiliar with. In addition, she could participate in training

such as safety coach training that supports nurses when they speak up about safety concerns

(Feng, Bobay, & Weiss, 2008). She could also suggest changes in the ED such as team nursing

to encourage teamwork, instead of individual nursing.

Summary

In conclusion, it is imperative that a department display a sense of honesty, resilience,

desire to learn, a consistent orientation for all staff, in-services to increase educational

opportunities, and encourage open communication where patient safety is of the utmost concern.

The safety of a patient lies not on the shoulders of one person, but on the entire department.
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References

Antonow, J. & Silver, M. (2000). Reducing medication errors in hospitals: A peer review

organization collaboration. The Joint Commission Journal on Quality Improvement

26(6), 332-340. Retrieved at

https://www.sciencedirect.com/science/article/pii/S1070324100260276

Feng, X., Bobay, K., & Weiss, M. (2008). Patient safety culture in nursing: A dimensional

concept analysis. Journal of Advanced Nursing 63(3), 310-319. Retrieved at

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2008.04728.x

Montesi, G. & Lechi, A. (2009). Prevention of medication errors: Detection and audit. British

Journal of Clinical Pharmacology 67(6), 651-655. Retrieved at

https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2125.2009.03422.x
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Appendix

Task Factors Staff Factors

(Two RNs did not follow policy (Urgent care background experience,

By checking heparin together) No experience with heparin drips,)

Wrong Infusion Rate

Environmental Factors Teamwork Factors

(Rare use of heparin drips (Lack of charge nurse support,

due to emergency department multiple new grad in ED w/o experience)

setting)