# A charge nurse is leading a root cause analysis after a patient received an incorrect medication dose due to a documentation error. Which action should be the charge nurse's FIRST priority in the root cause analysis process?

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## 문제

A charge nurse is leading a root cause analysis after a patient received an incorrect medication dose due to a documentation error. Which action should be the charge nurse's FIRST priority in the root cause analysis process?

## 보기

1. Assemble a multidisciplinary team to investigate the incident systematically **✔ 정답**
2. Interview the nurse who made the medication error to determine individual fault
3. Review the hospital's medication administration policies and procedures
4. Implement immediate corrective actions to prevent similar errors

**정답: 1**

## 해설

The first priority in root cause analysis is assembling a multidisciplinary team to systematically investigate system failures. Other options focus on individual fault, policy review, or immediate actions, which are premature without team-based analysis.

## 심화 해설

Understanding Root Cause Analysis (RCA) in Nursing Practice

Root cause analysis is a systematic process used in healthcare to identify the fundamental, underlying causes of adverse events or near misses. The primary goal is not to assign individual blame but to uncover system-level failures that allowed the error to occur. In the context of the NCLEX-RN, understanding the correct sequence of an RCA is critical for questions related to safety, quality improvement, and management of care.

Why a Multidisciplinary Team is the First Priority

The first step in a root cause analysis is to assemble a multidisciplinary team to investigate the incident systematically. This action is foundational because a single error, such as a documentation mistake leading to an incorrect medication dose, is rarely the result of one person's isolated action. As demonstrated in the analysis of a patient fall related to cough syncope, the investigation revealed not just one failure, but multiple systemic gaps including a lack of targeted nursing protocols, insufficient staff training, poor communication between medical and nursing staff, and a suboptimal environment [1]. A team comprising members from nursing, medicine, pharmacy, and administration is essential to map out the entire process and identify vulnerabilities from different professional perspectives.

Analysis of the Answer Choices

- Option 1 (Correct): Assembling a multidisciplinary team is the logical first priority. It establishes the framework for a fair, thorough, and system-focused investigation. Without a team, the analysis would be narrow and likely miss the interconnected factors that contribute to errors, such as the communication breakdowns identified in the cough syncope case study [1].

- Option 2: Interviewing the nurse involved to determine individual fault contradicts the core philosophy of an RCA. The purpose is to understand the system's failure, not to punish an individual. A blame culture suppresses reporting and prevents the identification of true systemic weaknesses. The focus must be on "what" happened and "why" the system allowed it, not "who" did it.

- Option 3: Reviewing the hospital's medication administration policies is a crucial step in the data collection and analysis phase of an RCA, but it is not the first priority. The team must first be formed to plan which policies, procedures, and workflows to review. The review is a tool used by the team, not a starting point.

- Option 4: Implementing immediate corrective actions is a vital outcome of the RCA process, but it comes after the analysis is complete. Acting prematurely, without understanding all contributing root causes, may only address a symptom of the problem. For instance, in the cough syncope case, interventions like developing nursing guidelines and enhancing staff training were implemented only after the systemic gaps were identified through analysis [1].References (research sources)

- [1]Application of Root Cause Analysis in Improving Care for Falls Associated With Cough Syncope.Research articleZhu F, Li Y, Liu L, Wang M. (2026) · DOI: 10.1002/ccr3.71873

## 임상 시나리오

Clinical Practice Guide: Initiating a Root Cause Analysis

When a safety event such as a medication error occurs, the charge nurse's immediate priority is to establish a structured, blame-free investigation. The following steps outline the initial phase of a root cause analysis (RCA) based on best practices from the National Patient Safety Foundation and The Joint Commission.

1. Assemble the Team

Form a multidisciplinary group immediately. Include frontline staff (nurses, pharmacists), supervisors, and a quality improvement representative. A diverse team ensures all perspectives on the workflow are captured.

2. Secure the Scene

Preserve any physical evidence (e.g., medication vials, MAR, equipment) and sequester relevant documentation. This prevents tampering and ensures data integrity for the investigation.

3. Conduct Initial Fact-Finding

Gather a timeline of events through open-ended, non-punitive staff interviews. Focus on "what" and "how" the system allowed the error, not "who" caused it. Avoid assigning individual blame.

4. Map the Process

Create a flowchart of the medication administration process as it actually occurred. Compare this to the written policy to identify deviations and system vulnerabilities.

**Key Safety Principle:** The goal of RCA is to identify latent system failures. Actions such as interviewing to determine individual fault or immediately implementing changes before analysis are premature and counterproductive to a just culture.

## 핵심 개념

- **Root Cause Analysis (RCA)** — A systematic process for identifying the fundamental, underlying causes of adverse events or near misses by focusing on system-level failures rather than individual blame.
- **Multidisciplinary Team** — A group of professionals from different disciplines (e.g., nursing, medicine, pharmacy) who collaborate to provide a comprehensive perspective during an investigation.
- **System Failure** — A flaw in the organizational structure, processes, or environment that allows errors to occur, as opposed to a single person's mistake.
- **Sentinel Event** — An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, which often triggers an RCA.

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