A nurse is conducting a root cause analysis of a medication error that occurred in their unit. Which of the following steps should the nurse take first?

This statement shows that the nursing student understands the importance of reporting errors or near misses, which are events that could have resulted in harm but did not. Reporting errors or near misses helps to identify system failures, root causes, and contributing factors that can be addressed to prevent similar errors in the future. Reporting errors or near misses also fosters a culture of safety, transparency, and learning in healthcare organizations.

Incorrect choices:

a) I should follow my intuition when making clinical decisions: This statement shows that the nursing student does not understand how intuition can lead to cognitive biases, heuristics, or shortcuts that can impair clinical reasoning and judgment. Intuition can be influenced by emotions, assumptions, stereotypes, or previous experiences that may not be relevant or applicable to the current situation. Nursing students should use evidence-based practice, critical thinking, and clinical guidelines when making clinical decisions.

b) I should use abbreviations and acronyms to save time when documenting: This statement shows that the nursing student does not understand how abbreviations and acronyms can cause communication errors, confusion, or misinterpretation among health care providers. Abbreviations and acronyms can have multiple meanings, vary by context or setting, or be easily mistaken for other words or symbols. Nursing students should use clear, concise, and standardized terminology when documenting.

d) I should work longer shifts to reduce handoffs and transitions of care: This statement shows that the nursing student does not understand how working longer shifts can increase fatigue, stress, burnout, or distraction among health care providers. Working longer shifts can impair physical, mental, and emotional well-being, as well as performance, attention, memory, and decision-making skills. Nursing students should work reasonable hours, take breaks, and ensure adequate rest and sleep. They should also use effective handoff techniques, such as SBAR (Situation-Background-Assessment-Recommendation).

The first step in a root cause analysis is to collect data and facts about what happened, when, where, how, and why. This includes interviewing the staff involved, reviewing medical records, policies, procedures, and protocols, and examining equipment and environmental factors. Gathering information and evidence helps to establish a timeline and a causal chain of events that led to the error.

Incorrect choices:

a) Identify all the factors that contributed to the error: This is a later step in a root cause analysis, after gathering information and evidence. Identifying contributing factors helps to determine the underlying causes and system failures that allowed the error to occur.

b) Implement corrective actions to prevent recurrence of the error: This is another later step in a root cause analysis, after identifying contributing factors. Implementing corrective actions involves developing and testing solutions that address the root causes and improve patient safety.

c) Communicate the findings and recommendations to the staff and stakeholders: This is the final step in a root cause analysis, after implementing corrective actions. Communicating the findings and recommendations involves sharing lessons learned, best practices, and feedback with those who are affected by or involved in preventing similar errors.