In partnership with a major medical center, senior-level nursing students completed a root cause analysis and implementation plan to address a unit-specific quality issue. To evaluate the project, unit leaders were asked their perceptions of the value of the projects and impact on patient care, as well as to provide exemplars depicting how the student root cause analysis work resulted in improved patient outcome and/or unit processes. Liaisons noted benefits of having an RCA team, with positive impact on patient outcomes and care processes.

Background: Patient-controlled analgesia (PCA) pumps are complex medical devices frequently used for postoperative pain control. Differences in how nurses program PCA pumps can lead to preventable medication errors. Purpose: To describe similarities and differences in how surgical nurses program PCA pumps. Methods: We conducted a qualitative study using video reflexive ethnography (VRE) to film nurses as they programmed a PCA pump. We spliced and collated videos into separate clips and showed to nursing leaders for their deliberation and action. Results: We found nurses ignored or immediately silenced alarms, were uncertain about the correct programming sequence, and interpreted how to load a syringe in the pump in multiple ways; in addition, the PCA pump design did not align with nurses' workflow. Conclusions: VRE was effective in visualizing common challenges nurses experienced during PCA pump programming. Nursing leaders are planning several nursing process changes due to these findings.