Running head: ROOT CAUSE ANALYSIS 1

Root Cause Analysis

Caroline Kissam

Bon Secours Memorial College of Nursing

NUR 3241

Professor Dr. Rani Sangha

January 26, 2020

Honor Code: “I pledge”

 ROOT CAUSE ANALYSIS 2

Introduction

The third floor cardiac telemetry / step down unit is one of the busiest units in our

hospital. It is a high turnover area because the patients typical length of stay is approximately

24-48 hours. Day shift is the most chaotic shift because the patients are moving in and out so

quickly and are leaving the floor for cath lab procedures. Nurses who work in this unit

usually carry 4 patients. On this particular day a nurse called in leaving the other nurses to carry

an extra patient.

The event occurred at approximately 10 am, which is probably the busiest time of day.

Half of the patients on the floor are being discharged between 8 and 10, the remaining patients

are being prepped for procedures, getting their am care, waiting for meds or getting cardiac

rehab. Consulting doctors are rounding. Mr Doe was admitted the day before with a heart failure

exacerbation and a shock from his defibrillator. He was found at work unconscious by a co-

worker. EMS was called and brought him to our hospital. He was evaluated in the ED and

found to be in acute on chronic heart failure. He was actually scheduled to have

his ICD upgraded to a bi-ventricular device and undergo a VT ablation in the near future.

Interrogation of his current dual chamber ICD revealed that Mr. Doe had been shocked twice by

his ICD for Vfib. He also had a recent history of receiving ICD shocks for the same reason. Mr.

Doe was admitted and treated for his CHF exacerbation. He was also scheduled to have an

echocardiogram.

Mr Doe’s Nurse was Bob. Bob was a relatively new nurse that had only been

off orientation for one month. He was having to take care of 5 patients instead of the usual

assignment of 4 patients because of the call in. Two of his patients were being discharged and

ROOT CAUSE ANALYSIS 3

two were going for procedures. The discharges and the procedures were going to take place

during the first 4 hours of his shift. The transporter arrived to take Mr Doe down for his echo

and he called Bob to take the telemetry monitor off of Mr. Doe. Bob came to the beside,

notified the monitor techs that he was removing Mr. Doe’s monitor for transport. Mr. Doe went

for his Echo. Approximately 1 hour later transport returned Mr. Doe to his room after stopping

by the nursing station to notify them of his return. There was no unit secretary at the desk and

the rest of the staff were busy with patients. The transporter decided to take the patient on to the

room hoping that someone would notice his return and come put the telemetry monitor back on.

The patient requested to go to the bathroom so the transporter allowed him to and then

proceeded to leave the patient and go notify the unit secretary of the patients return. This time

the secretary was at her desk. She notified Bob that Mr. Doe returned from Echo. Bob was very

busy and was being pulled in more than on direction. The other staff on unit were also busy with

their own patients. Bob told the secretary he was coming but stopped to address another

patient’s request. While Mr. Doe was in the rest room his defibrillator fired again but this time it

wasn’t successful at terminating the Vfib and Mr. Doe passed away. Bob got to Mr. Doe’s room

as soon as he could and found Mr. Doe in the bathroom on the floor unresponsive, without a

pulse. A code was called. All efforts to resuscitate Mr. Doe failed. We are unsure exactly how

long Mr. Doe was down but can estimate that he was in his room approximately 10 minutes

before Bob found him.

Problem Statement

This root cause analysis will investigate why Mr. Doe was not immediately put back on

telemetry when he returned to his room.

 ROOT CAUSE ANALYSIS 4

Causes of the problem

The transporter allowed Mr. Doe to go to the bathroom before his telemetry monitor was

re-applied.

Contributing Factors

This incident occurred at the busiest time of the day. Patients were coming and going to

and from procedures. The unit was short staffed due to a call in so the nurses were carrying

more patients than they would normally. All staff members were very busy. Bob was a new

nurses with very little experience. The secretary was not at her desk and the transporter failed to

follow the procedure.

Recommendations

This patient was probably one of the sicker patients on this unit. In my opinion he should

have been accompanied by a nurse to the Echo or the Echo should have been done at the bedside.

He was receiving frequent ICD shocks for VFib so the device upgrade and ablation should have

been moved up. This patient should have been assigned to a more experienced nurse due since

Bob was already overwhelmed by having to carry an extra patient. The transported should have

never allowed the patient to go to the bathroom before having his monitor replaced which leads

me to believe that there is a need for some re-education for the transporters regarding the policy

and procedures of the telemetry unit.

Nurses Role in Recovery Process

Bob should have realized that Mr. Doe was at high risk for another ICD shock because he

was already scheduled for a device upgrade and a VT ablation so he had not received treatment

for this condition. Bob should have prioritized the needs of his patients and gone immediately to

 ROOT CAUSE ANALYSIS 5

apply the telemetry monitor. If Bob were not able to do it himself, he should have asked for help

from his charge nurse. If Bob had more experience, he would have likely realized that Mr. Doe

needed closer observation.

Conclusion

There were so many thing wrong with this situation. Bob was overwhelmed by the

number of patients he was caring for and his lack of experience. The transporter failed to follow

the procedure for returning telemetry patients to their room. No one took the time think through

this patient’s situation. He was a high acuity patient who should have had a higher level of care.

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Appendix:

Work
Procedure
Environment

Policy & procedure loosely

Short sta ed followed.

Patient was not

Many discharges and placed back on
procedures
telemetry
Poor communication
monitor upon
returning to unit.
Inexperienced Sta

Relatively new sta

Training Team
ff

f
f