A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis in order to identify the essential cause of this error, what question should be asked first?

Question

Quizplus · Accepted Answer

Asking "why" is essential to the process of root cause analysis. Asking a series of "why" questions can reveal underlying causes. Each of the other listed questions addresses a valid aspect of the event, but none address the underlying causes, which is the focus of root cause analysis.

A Nurse Failed to Document the Administration of a Client's