Running

Head: ROOT CAUSE ANALYSIS

Root Cause Analysis for School Nursing

Elizabeth Blanton
Bon Secours Memorial College of Nursing
Instructor Connie Garrett, MSN, RN
NUR3206
March 9, 2016
Honor Code I pledge

Running Head: ROOT CAUSE ANALYSIS

Root Cause Analysis for School Nursing

The following root cause analysis pertains to the field of school nursing and analyzes a
potential adverse event that could likely occur in the school setting. Food allergies and the risk
of anaphylaxis are hot topics in school nursing, as food allergies are one of the most common
conditions that school nurses manage (Weiss et al, 2004). In this scenario, a childs severe
allergic reaction is not recognized and treatment is delayed, which leads to an anaphylactic
reaction. Peanut allergies represent the most common cause of anaphylaxis in children (Weiss et
all, 2004). Its important for school nurses to prepare for all risks surrounding food allergies and
understand how errors in student care happen and lead to adverse events. In order to examine the
cause of an error or adverse event, organizations can complete a root cause analysis. One
example of a framework for completing a root cause analysis was developed by The Joint
Commission. In using the Joint Commissions model, an organization can examine the possible
root causes of an error and develop a recommended action plan for avoiding similar incidents in
the future (Joint Commission, 2013).
A 1st grade student needs to see the nurse at 10 a.m. on Halloween Day. The student is
complaining of a stomachache and cough. The Lower School Nurse is currently unavailable, as
she is assisting a diabetic student with her care in the gymnasium on the other side of campus.
An assistant teacher volunteers to walk to the 1st grade student to the Middle/Upper School
Nurse for assistance. The Middle/Upper School Nurse currently has a line of upper school
students waiting to see her, and she has one student in the bathroom vomiting and one student
crying because of a poor grade on a test. The Middle/Upper School Nurse is unfamiliar with the
1st grade student. The nurse takes the students temperature, inspects her throat, inspects and
palpates her abdomen, and talks to the assistant teacher about possible causes for the students

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ailments. After performing her assessment, the nurse decides to give the student a cup of
gingerale and send her back to class. While walking back to class at 10:20 a.m., the student
suddenly vomits multiple times, and then falls to the ground. She has stopped breathing and is
unresponsive. It is later determined that the student had a known severe peanut allergy and
consumed a cookie made in a factory that processed foods containing peanuts during a class
party for Halloween.
The intended process at this school of 1,000 students is for the Lower School Nurse to
treat all lower school students, and the Middle/Upper School Nurse to treat all students from the
middle and upper divisions. The nurse in each division is familiar with the students in her
specific division, but may not be familiar with students in other divisions. Individual student
emergency medications, such as Epi-Pens, are stored in the nurses clinics, where there are also
non-student specific Epi-Pens available. Nurses review a students electronic medical alert
during each visit; allergy alerts are highlighted boldly in each electronic medical record. Each
student with a health concern has an Emergency Medical Plan stored in the electronic medical
record. Assistant teachers float between grades kindergarten and 2nd grade and are not assigned
to a specific classroom during the school day. If the nurse in a division is not available, the
office staff coordinates with the nurse in a different division to provide assistance to a student
who needs nursing care. There is no written policy for coordinating care across divisions or for
having an assistant teacher take a student to the clinic; in addition, the written policy regarding
food in the classroom is vague according to teachers. In order to prevent adverse events related
to food allergies, nurses educate teachers at all-school meetings, divisional meetings, and grade
level meetings at the start of each school year. Written medical alerts by grade level are also
distributed to teachers.

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Staffing issues are one factor that contributed to this adverse event. First, the Lower
School Nurse was assisting another student away from the clinic, requiring a contingency plan be
used; the Middle/Upper School Nurse treated the 1st grade student. The Middle/Upper School
Nurse was not familiar with the students medical history and was not aware of current activities
in the 1st grade. She also had a clinic full of students and a line of students out the door waiting
to be seen when the 1st grade student visited her clinic. She was very busy and unable to focus
on the assessment of the 1st grade student. Second, as the classroom teacher was unable to take
the 1st grade student to the clinic, an assistant teacher was asked to walk the student to the nurse.
The assistant teacher did not work all day in the 1st grader students classroom and was
unfamiliar with the class activities for the day; in addition, she did not consistently work in the
same classroom each day and was unfamiliar with the 1st grade student.
There were communication barriers that contributed to this adverse event. The
Middle/Upper School Nurse was not notified of the Halloween Party in the students classroom.
The assistant teacher was not given any background on the students current medical condition,
including notification of a classroom party or a reminder of the students allergy risk. In
addition, policy or method root causes also contributed to both the communication and staffing
issues. Specific policy/method root causes include the lack of a written policy for both having a
student visit the nurse in another division and for having an assistant teacher take a student to the
nurse. Finally, the written policy for bringing food into the classroom was vague and did not
clearly state the types of foods that are allowed or prohibited. The classroom food policy also did
not require advance notification of parents or the school nurse when food would be given to
students. In order to manage a students food allergy at school, effective advanced
communication between the nurse, school, and parents is essential (Fitzsimons et al, 2012).

Running Head: ROOT CAUSE ANALYSIS

Human factors that contributed to the adverse event include the assistant teacher
forgetting that the student had a medical history of severe food allergies. Teachers are given
medical alerts for students at the start of each school year, but the assistant teacher forgot this
particular students history. Assistant teachers help in multiple classrooms across multiple grade
levels, which results in assisting lead teachers with over 150 children. A second human factor
was that the Middle/Upper School Nurse did not perform her assessment as expected. She did
not check the 1st grade students electronic medical record, which would have identified the
students severe food allergy. Prompt recognition of a students allergic reaction is crucial in
managing food allergies (Fitzsimons et al, 2012). While the necessary information was available
to the nurse, it was not reviewed. The Middle/Upper School Nurse was busy and rushing, as she
had multiple students in the clinic and others waiting to see her. Distraction and interruptions are
often key factors in causing errors in the nursing field. In one study, 32% of the nurses
interviewed listed distractions and interruptions as leading causes for making an error (Armitage
& Knapman, 2003).
The organizational culture that contributed to the adverse event is the acceptance of the
current nurse to student ratio by the schools administration. The current ratio for the Lower
School Nurse is 1:400; the current ratio for the Middle/Upper School nurse is 1:600. This
includes care of 7 diabetics, 30 asthmatics, 40 students with food allergies, 5 students with a
seizure history, and 10 students with other chronic conditions requiring daily interventions.
Authors in one study noted that the needs of patients in todays world are much greater than even
ten years ago (Koetting, 2010). This holds true in the field of school nursing as well. While the
National Association of School Nurses (NASN) has a recommended ratio, there is no legally
binding nurse to patient ratio in Virginia. According to NASN, recommended ratios vary based

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on the complexity of student healthcare needs. In schools with few students requiring daily care,
the recommended ratio is 1:750 (NASN, 2015). As acuity increases and the need for daily
nursing interventions increases, the recommended ratio is 1:225 (NASN, 2015). Based on the
acuity and healthcare needs of the student population at this school, the appropriate nurse to
student ratio would fall between 1:225 and 1:750. Staffing should be adequate in the lower
school division, but in the upper and middle school divisions, the staffing ratio may not meet
NASN standards.
Finally, a root cause that is unchangeable is the large size of the campus. If a nurse is
pulled away from the clinic to treat a student in a different location, she may not be immediately
available to assist students on another part of the campus. This is a common problem for school
nurses at other schools, as school nurses may not be readily available when a reaction occurs
(Weiss et all, 2004, p. 273) when providing care for other students. The nurses in this scenario
are always available by cell phone and are able to cross the campus at a brisk pace in
approximately four minutes, if not assisting another student.
The following action items are changes that can be made to prevent a similar event from
occurring in the future:

Action Item #1 is to develop written policies for providing nursing care across divisions.
The policy should include the communication required from teachers and office staff to the
nurse, including the current situation and student background. The policy should require
that the classroom teacher provide report to the office staff or assistant teacher if the
classroom teacher is not able to take the student to the nurse.

Action Item #2 is to restructure the use of assistant teachers in grades kindergarten through
2nd grade. Assistant teachers will be assigned a specific classroom, or grade level at a

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minimum, to allow the assistant teachers the opportunity to become familiar with a set
group of students.

Action Item #3 is to reinforce with the nursing and athletic training staff the expected tasks
necessary during a student clinic visit, including reviewing the students electronic medical
history.

Action Item #4 is to adjust nurse to student ratios to accommodate the healthcare needs of
the student body. Staffing can be split between the Lower School Nurse and Middle/Upper
School Nurse as student acuity changes between divisions.

Action Item #5 is to write a clear policy on food in the classroom. In one study, 61% of
students allergic reactions were caused by food supplied by the school (Weiss et all,
2004). The policy should identify which foods are permissible in the classroom and which
foods are prohibited. The nurse and parents should be given advance notice of when food
will be served in order to arrange alternative food for children with food allergies or assist
in arranging safe food choices for the classroom.

Action Item #6 is to provide more education to the teachers regarding food allergies. Food
allergy training at the start of the year may not be sufficient in ensuring that teachers are
confident in their understanding of the causes of anaphylactic reactions, the importance of
considering a students medical history when a child is ill, and how to implement an
emergency plan when needed. Additional training sessions should be held throughout the
year for teachers.

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Fishbone Diagram
The fishbone diagram is used to help identify multiple causes of an error. This diagram method
allows an organization to look at many categories of possible root causes and not focus on the
obvious causes (Phillips & Simmonds, 2013). The categories in this scenario include Method &
Policies, Organizational Culture, Staffing, Human Factors, Communication, and Environment.

Method & Policies

No policy for
visiting different
division nurse

Organizational Culture
Acceptance of nurse
to student ratio

Staffing
Different divisional
nurse visited

Assistant Teacher
did not know
student well

No clear policy for

food in classrooms

MS/US Nurse did

not know student
LS Nurse
unavailable to assist
student

MS/US Nurse busy

and distracted

Problem
Statement

Student had severe

allergic rxn resulting
in hospitalization

Assistant Teacher
forgot student's
food allergy

MS/US Nurse not

told about party

Large Campus

Environment

No report given to
Assistant Teacher
Communication

MS/US Nurse did

not check EHR
Human

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9
References

Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: a literature
review. Journal Of Nursing Management, 11(2), 130-140.
Fitzsimons, R., Kane, P., & Fox, A. (2012). Anaphylaxis: Managing emergencies in
school. British Journal Of School Nursing, 7(3), 122-126.
Koetting, M. (2010). Safety in numbers: nurse-to-patient ratios and the future of health
care./Hospital: man, woman, birth, death, infinity, plus red tape, bad behavior, money, god,
and diversity on steroids. Journal Of Health Politics, Policy & Law, 35(1), 127-133.
National Association of School Nurses. (2015). School nurse workload: Staffing for safe care.
Silver Spring, MD.
Phillips, J., & Simmonds, L. (2013). Change management tools part 1: Using fishbone analysis
to investigate problems. Nursing Times, 109(15), 18-20.
The Joint Commission. (2013, March). A framework for a root cause analysis and action plan in
response to a sentinel event [PDF]. Retrieved from
http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_a
ction_plan/
Weiss, C., Muoz-Furlong, A., Furlong, T., & Arbit, J. (2004). Impact of food allergies on
school nursing practice. Journal Of School Nursing (Allen Press Publishing Services
Inc.), 20(5), 268-278