1. BACKGROUND – Add more context here about the community and the hospital it serves, what are the pressures on the health system

2.METHODOLOGY –

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

5.DATA MANAGEMENT

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