Nursing Leadership: Root Cause Analysis-Patient Scenario

Root Cause Analysis- Patient Scenario

Nursing research essay writing is not everyone’s cup of tea. Below I present patient scenario and how essay professors like myself would approach the task for an assured A score.

62 year old female with history of CHF was admitted from the Emergency Department (ED) with Left Lower Lobe Pneumonia. She has been living independently at home with no assistance needed with care. The admission nurse came on duty at 11pm and got report from the ED nurse. The patient’s vital signs were normal. The patient was complaining of pain with inspiration and difficulty sleeping. The nurse administered a sleeping pill and pain medication at 1130pm. 

The unit was short-staffed by two nurses therefore, the admitting nurse did not have time to complete a fall risk assessment on this patient. The nurse  put all 4 siderails up on the patient’s bed as she had another new admission from the ED and knew she would not be near the patient’s room. 

At 0300, another nurse walking by the patient’s room heard a noise and went in the room to investigate. The patient was found on floor and was c/o severe right hip pain. The nurse also found the oxygen tubing wrapped around the IV pump, 2 extra chairs in the room and the call light clipped to the suction outlet on the wall. 

The patient had x-rays of the right hip and was found to have a right hip fracture. The next day she was taken to surgery for a hip repair. During surgery she had an acute myocardial infarction (AMI) and died while on the operating room table.

When the nurse was called in for an interview the next day, the nurse manager asked the nurse if she knew the fall policy for the hospital. The nurse stated that she had just been hired 2 weeks ago, that her hospital orientation had been postponed, and that she had not reviewed any hospital policies. 


The Solution from the Best Essay Helper for Nursing

The provided table below is used to answer the questions for the case. Read it carefully and if you have any questions or need nursing essay help, feel free to reach out to me at I work in a service I consider to provide the   best essay writing service for nursing. As a nursing expert, I have unshakable confidence in myself to tackle any nursing tasks brought to my attention by clients like you. If you have the time, you might read the solution to the case in question to learn how to answer such assignments. 





A 62-year-old patient with chronic heart failure on admission received a sedative and an analgesic to relieve her pain and put her to sleep. Later, the patient fell from the bed and broke her left hip. During the surgery to correct the fracture, the patient sufferers a heart attack and passes on. 


The event occurred on the night of admission at 0300hrs.


  • The calling system was not in use
  • The nurse did not perform a patient risk assessment 
  • The unit was short-staffed
  • The nurse had not completed the orientation
  • The room was cluttered
  • The room was not adequately prepared for the patient.
  • The was no close monitoring of the patient by the nurse since she was alone and had another admission to attend.



Short staffing of nurses in the unit.


  • The patient was not educated on the risk of falling, to call for assistance when in need.
  • The nurse had not completed the orientation as necessary


  • The call light was clipped to the suction outlet. The patient was not informed how to call for assistance.
  • The nurse did not ask for assistance or help from the supervisors or nurses in other units.
  • The nurse had no hospital orientation.

___ Other(list):

  The nurse had another admission to attend.


Malfunction of equipment 

  • The bedside rails did not prevent the patient from falling.
  • The call bell was far from the patient

Preventative maintenance not performed 

  • The bed and rails may not have been checked for functionality to detect any fault for repair.
  • The proximity of the call system to the patient was not assessed

Inappropriate use of equipment 

Two extra chairs and the I.V pump were in the room were not required.

Equipment not available when needed 

The call light was clipped to the suction outlet not available to the patient.

Inadequate controls or alarms on equipment

None was identified in the patient room





Path obstructed 

Two extra chairs, an I.V pump, and the call light were all clipped on the suction outlet.

Area cramped or cluttered 

  • The patient’s room had unnecessary equipment or items.
  • Area under construction 

Inadequate systems to identify a high-risk area

The nurse who was alone in the unit had many patients to attend, and had not completed the orientation to the hospital received a patient with a high risk of falling and went ahead to receive another admission without giving due attention to the first one.

Inadequate safety procedures 

The nurse had not reviewed the fall policy, safety procedures, and other hospital policies.

Area not meeting code/regulation 

No hospital orientation for the new nurse.

Other (list):

  • The nurse did not follow the fall policy and safety procedures.
  • The patient communication policy was not followed.
  • The equipment management procedure was not followed.
  • The hospital orientation procedure and policy were not followed.


  • No supervision by the seniors to check on the unit.
  • Allocating a new staff on night duty alone.
  • No patient monitoring was done.
  2. Nurse versus patient ratio staffing – The hospital should ensure that the nurses working any shift are adequate for the patients admitted to allowing timely and procedural response to patient needs. 
  3. Hospital orientation for new nurses - All new nurses should undergo mandatory orientation to familiarize them with the relevant procedures and policies applicable in the hospital
  4. Reviewing hospital procedures and policy by the nurses – The hospital should develop a continual improvement system that checks the suitability of the existing procedures and modifies them when necessary. It should also train nurses on these procedures through continuous education.

Cite this page Leadership: Root Cause Analysis-Patient Scenario. (2022 July, 30). 


Tutor Pharaoh Jr.

Tutor Pharaoh Jr.

Hello, my name is Pharaoh. I joined the team as a part-time writer. Besides working for the company, I worked as an academic tutor at one of the nursing colleges. I have a master’s degree in clinical nursing. I have written over 2000 highly-ranked nursing and healthcare papers with this company. I also have a niche in Psychology, Healthcare, and Sports Science. I, thus, have the prerequisite knowledge, experience, and expertise to guide you through your most traumatizing assignments.

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