You are the nurse manager on an ICU unit.

The unit was exceptionally busy as you had a call in from a nurse and your CNA was pulled to another unit. Nurse Bonnie has 3 patients that day due to the call in. She was about to deliver medications when she received a call from a physician that needed to change orders on a very critical patient. Bonnie looked for another nurse to take the order, but there were none available. Everyone was very busy. So she left the PYXIS and went to answer the phone. She went back to Patient A’s room and administered the medication.

About an hour later, Nurse Bonnie comes to you and tells you she gave the medication for Patient B to Patient A. She had checked on the patient and there were no adverse reactions.

You report this incident to quality and call the patient A’s physician to report the error. Since there were no adverse reactions, the doctor said to continue to report this to Quality.

The Quality and the Legal department call you to do an RCA (Root Cause Analysis) on the situation. They told you to do the investigation on the incident.

During your investigation of the incident, you find out the nurse did not have the order sheet with her when she went to the PYXUS. After the phone call, she went into the patient’s room and gave the medication. After the phone call, she went into the patient’s room and gave the medication. When you talked to the nurse, she admitted she inadvertently put Patient B’s medication in her pocket and answered the phone call. She then went to Patient A’s room and administered the medication.

As you continued your investigation you went to the J oint Commission website for the new National Patient Safety Goals

(Links to an external site.)

. You chose the simplified version of the NPG 2021.

Question

What would you report in the RCA as the cause?