Purpose: This assessment enables students to demonstrate sound understanding of the application of professional nursing standards, national health standards and organisational policy related to...

NRSG378 Extended Clinical Reasoning – Assessment 2 Project
Root Cause Analysis (RCA) Report - Template
INSTRUCTIONS:
Please use this template to complete assessment 2. You will choose from either ONE of two case studies provided to complete a RCA.
Your discussion must be cited and supported by a wide range of relevant and credible sources for each question below. There is no need to include an introduction or conclusion.
You are required to include a final reference list at the end. A minimum of 15 high quality resources are to be used. All answers must be supported using a variety of high-quality primary evidence. Avoid using any one source repetitively.
1. Discussion of identified root cause
Briefly discuss how the identified root cause has led to the outcome for the patient.
    
The main root cause in this case is the use of unsterile instruments during the surgical process of Mrs. Bentley (Mehtal et al., 2020). This kind of failure in the sterilization process has been found to be contributing to the negative results that have been faced the patient. Sterile instruments are needed here in order to prevent surgical site infections (SSIs), which can lead to some of the serious issues, as seen in Mrs. Bentley's case (Berman et al., 2021). The use of unsterile instruments introduced some of the bacteria and pathogens directly into Mrs. Bentley's surgical site, and this actually increased the risk of infection. As a result, Mrs. Bentley also had a kind of post-operative infection, which was indicated by symptoms such as increased levels of temperature, severe wound discharge, and other signs or symptoms of sepsiss or other infections. Delayed check of these symptoms due to inadequate monitoring and assessment also helped in increasing the situation, leading to a further worsening of the health condition for Mrs. Bentley (Mohsen et al., 2020). More than that, the instrument sterilization also had its contribution to the longer periods of hospitalization of Mrs. Bentley, the need for ICU admission, more levels of ventilation, use of potent antibiotics, and additional surgery for treating the infection.
2. Identification and discussion of contributing factors
Discuss three (3) contributing factors which have likely led to this sentinel event.
    The three main contribution factors for the patient in the case study here are given below:
· Time pressure and rushed preparation: The delay in Mrs. Bentley's surgery happened due to complications with the previous issue patient in context of the time pressure for the operating theatre (OT) staff (Eriksson et al., 2020). Rushed preparation was found here in the case study, which was actually leading to some kinds of issues and shortcuts in the sterilization process. The tiredness of the OT staff may have also further restricted in their ability to perform proper nursing checks, which increased the chance of errors. This time pressure also had its contribution which also helped to ensure the fact that all instruments were properly sterilized before use.
· Inadequate communication and handover: The handover process between RN Steve and RN Misha was incomplete and lacked transferring proper information about the condition of Mrs. Bentley' and the post-operative care she is in immediate need (Ahn et al., 2021). Steve failed to get the importance of Mrs. Bentley's high levels of body temperature and missed observations, and in this case, it can be stated that Misha relied mainly on initial assessments without making any kinds of further evaluations. This breakdown in communication and handover compromised the proper levels of continuity of care, leading to a some negative recognition of Mrs. Bentley's bad health condition and delayed interventions.
· Shortages in nursing staff and workload pressures: The night shift was very much challenging due to two staff members calling in sick, and this also resulted in increased workload and reduced number of staffs in the hospital settings (Worringer et al., 2020). As a result, signs of patient deterioration, such as confusion, elevated temperature, and shivering, were not very much addressed or escalated, which also allowed the infection to progress unchecked until the morning shift nurses came.
3. Links to NMBA RN Standards for Practice
Identify and discuss two (2) separate NMBA RN Standards which were not practiced or maintained by the nurse(s) involved in this sentinel event, that may have led to the identified root cause. You need to identify and discuss specific sub-standards (e.g. standard 7.2, not just standard 7).
    1
    
Standard 5: Nursing Practice Decision-Making and Leadership:
Sub-standard 5.3: "Nurses must documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes." The nurses has been found to face failure in the process of checking on the need to face bad condition of Mrs. Bentley (Safetyandquality.gov.au, 2023). Despite her elevated temperature, confusion, and other signs of distress, they did not promptly recognize these symptoms as potential indicators of...