A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked
When performing root cause analysis in order to identify the essential cause of this error, what question should first be asked?
A) "Has this, or something very similar, ever happened on the unit before?"
B) "Why did the second nurse administer this drug to the client?"
C) "What could the two nurses have done to ensure this didn't happen?"
D) "What were the possible adverse outcomes that could have resulted from this error?"
Ans: B
Feedback:
Asking "why" is essential to the process of root cause analysis. Asking a series of "why" questions can reveal underlying causes. Each of the other listed questions addresses a valid aspect of the event, but none address the underlying causes, which is the focus of root cause analysis.
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