The document is a cause and effect diagram from the department of risk management analyzing the factors that led to a medication error in administration that caused a death. It identifies shortages in manpower, specifically nursing staff and doctors, as well as inadequate staffing plans and distribution of staff as root causes. It also lists poor communication between care providers, inadequate staff orientation and training, and a lack of monitoring of nursing staff as contributing factors.
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O.R case
1. -DepartmentRisk Management
CAUSE AND EFFECT DIAGRAM
Manpower Material
File NO
Staff Procedure
I.V monitoring policy not followed by
Shortage of nursing staff and nursing staff
doctors
Policy ”Observation d E.R not
Inadequate staffing plan. Distribution of ””implemented
staff not adequate
Inadequate E.R staff planning due to shortage
Of staff
Medication Error –
Administration- Leads
Poor communication between care providers to Death
Staff orientation not adequate
Poor documentation in E.R and medical record
Lack of monitoring monitoring of staff nurse
Communication among staff inadequate in the afternoon & night duties
Methods of
Communication TRAINING
12/5/31
Dr. Dawood Risk Manager