Reviewing the Taxonomy of Error, Root Cause Analysis, and Practice Responsibility or
TERCAP is a database with compiled information to ascertain the root cause analysis of nursing
practice breakdown from the healthcare system and individual perspectives facilitate
developmental nursing strategies (Thomas, 2011).
According to the TERCAP outline provided, a reasonably new nurse with nine months'
experience on a unit presented failed to assess the patient per facility protocol. Failure to follow
facility protocol resulted in a surgical patient's fall and attached extensive time to the healing
process. Nursing situations, human error, and organizational factors contributed to the accident.
Situational factors such as exhaustion or burnout likely from working consecutive twelve-hour
shifts, personal issues as the nurse in question are 29 weeks pregnant, which can also cause
fatigue and influence behaviors.
The nurse chose not to assess the patient as duty requires, leading to the patient falling. Being
exhausted can quickly cause the nurse to be unaware of the patient's needs or lack of sound
clinical judgment. Situational factors that undeviatingly affected the patient are lack of access to
a sound alarm system, lack of staff, and bathroom orientation (Frank, 2020).
Lack of judgment/experience and poor clinical skills for the particular unit are factors of the
nurse's situation that contributed to the fall. Interventions and lack of patient care planning were
sufficient factors. By neglecting to assess the patient who is post-surgical of the vertebral region