Why? Lack of management skills of the ward managerRoot cause

Individual Case study
On discharge from the ward, a patient was given the wrong discharge medication. Further investigated discovered that the staff had not followed the hospital guidelines on the safe management of medicines. The staff involved stated that the unit was very busy. She had only been working on the unit for three months. It was also discovered that she had not completed her medication competencies and that her induction was not complete. The unit did have adequate orientation for new staff. They where also not aware of where to access the hospital guideline.
When this was raised with the manager, they where not aware that staff competencies where not up to date and they felt that this was the responsibility of the education team.

Five whys
Problem: Wrong discharge medication given to patient
Why? Hospital guideline was not followed
Why? Staff was not aware of the guidelines
Why? Training and education for staff in the unit was lacking
Why? No clear organisation of the nursing staff and identification of training needs
Why? Lack of management skills of the ward manager- Root cause

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