Fact Pattern for Root Cause Analysis


A 75-year-old female is an inpatient in bed #1 of Room 10 on a medical telemetry unit. She has been admitted for pneumonia. She is slightly confused. No family is with her in the hospital at this time. The nurse introduces herself to the patient, asks her if she needs anything right away, and says she will return shortly with the patient’s medications. The nurse also has the patient in the other bed (bed #2) of the same room, the patient’s roommate. The nurse is very busy because of the high patient load on the unit that night shift and due to being short one nurse who called out sick.

The nurse comes in to see the patient in bed #1 again and assess her and give her her medications. After the patient swallows all of the pills and is ready to get settled for the night to go to sleep, the nurse realizes that she just gave, to the patient in bed #1, the medications intended for the patient in bed #2.

Relevant Hospital Policies:

1) There should be at least five nurses on the unit on a night shift if the patient beds are full. Contact nursing supervisor ASAP if this is not the case.

2) Each patient’s medications must be dispensed (taken out of the medication machine) and administered (given to the patient) individually. A nurse should not bring medicine to two patients at once.

3) All patient medications must be run through the electronic barcoding medication administration system prior to the patient taking them.

4) Before administering medication, the nurse should check two patient identifiers (name, date of birth, address, etc.). They are usually available in the medical record or on the patient identification band, or a competent patient can tell you too.

5) All patient medication errors must be reported via the hospital patient safety reporting system.


You are the hospital’s risk management specialist. Please explain what you would do after this medical error, and any order you might do it in. If you choose a specific order of events, explain why. What questions would you ask? What staff would you interview? What policies might you review in detail? Who would you want in the room for a root cause analysis meeting? What else might we need to know to complete a root cause analysis? What might you do to prevent this problem in the future?

Remember, when a patient safety/risk management specialist receives information on an event, it is usually incomplete. Part of the process requires knowing the right questions to ask and who are the right people to be involved.

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