1. BACKGROUND – Add more context here about the community and the hospital it serves, what are the pressures on the health system
3.FORMULATE FOCUS QUESTION BY MAKING GOOD USE OF 5 WHY’S- The issue identified- a patient died as a result of cardiac arrest .
• Why? Due to prescription error written by Doctor Peters and administered by Nurse Smith.
• Why did Nurse Smith administer the drug? Because was tired and experiencing burnout and the matron wouldn’t listen to her.
• Why was she experiencing burnout? She was asked to do extra shift by the matron and she did not decline as she does not want to offend the matron.
• Why did she not decline the matron’s request? She feel if she does, she will look irresponsible and the matron will feel offended.
• Why did she feel she will feel irresponsible and the matron will be annoyed? Because she is not assertive.
• Why is she not assertive?
—Discuss how the 5 whys has helped you focus your question and the search terms you use next
4. COLLECT RELEVANT INFORMATION
6.CONNECTING THE RELEVANT INFORMATION
7. Level of Qualification
8.Poor Leadership Style
9.Lack of mentorship structure
10. CONCLUSION/CREATING A NEW WAY
11. SHARING LEARNING/ RECOMMENDATION – Consider very specifically how these recommendations might apply to your scenario and hospital.
12. Appendix 1: PERSONAL REFLECTION
13.APPENDIX 2: CONVERSATION WITH COLLEAGUES
14. APPENDIX 3; INQUIRY MODEL
15.APPENDIX 4; CASP APPRAISAL TOOL