| Course | NUR-8420 Organizational and Systems Leadership II |
|---|---|
| Module | Module 2 |
| Paper type | Patient safety paper: systems analysis of an adverse event |
| Length | About 1,132 words, 7 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | Doctor of Nursing Practice |
| Updated | October 2026 |
Free sample paper for NUR 8420 Module 2
Two Boluses, One Order: A SEIPS Analysis of a Heparin Event on a Camden Telemetry Unit
Student Name
Doctor of Nursing Practice, Thomas Edison State University
NUR-8420: Organizational and Systems Leadership II
Mentor Name
Month Day, Year
Two Boluses, One Order: A SEIPS Analysis of a Heparin Event on a Camden Telemetry Unit
The Event
Every detail of this event is invented for teaching. A 68-year-old man admitted to a telemetry unit at a 450-bed hospital in Camden with a new blood clot in his leg was started on heparin through a pump, dosed by his weight. The admitting order set included a bolus dose given at the start of the infusion. The night nurse gave the bolus from the infusion pump and started the drip. At 0700, the day nurse, a float from another unit, found a printed heparin protocol sheet at the bedside listing a bolus as the first step with no place to record that it had been given. Seeing no bolus in the medication record because it had been charted as part of the infusion, she gave a second bolus. Six hours later the patient's clotting time was well above range, and that evening he developed bleeding from the gut that required two units of blood. He recovered and went home on day six.
The first draft of the internal review concluded that the day nurse had failed to check the record and recommended counseling and a competency review. The patient safety officer, a nurse with a DNP, asked the review team to start again with a systems model.
Person and System Approaches
Reason (2000) described two ways of thinking about error. The person approach locates error in the individual, in lapses of memory, attention or care, and answers it with retraining, warnings and discipline. By contrast, the system approach takes human error as a given and asks which barriers ought to have stopped this one. Reason pictured those defenses as slices of Swiss cheese whose holes come from active failures, the slips and mistakes made by people giving care, and by latent conditions, the decisions of designers, managers and procedure writers that sit unnoticed until they line up with an active failure. He argued that the person approach is attractive because blaming one person is quicker and feels just, but it leaves the hidden weaknesses waiting for whoever works the next shift.
The SEIPS Model
Carayon et al. (2006) built the SEIPS model, short for Systems Engineering Initiative for Patient Safety, to give the system approach a working structure. In the model, a work system made of five parts that act on each other (the individual worker, the tasks, the tools and technology in use, the physical surroundings and the wider organization) shapes the processes of care, and the processes in turn decide what happens to patients, to the staff themselves and to the hospital. A problem in any part can create risk, and changing one part changes how the others behave.
The review team mapped the heparin event onto those five parts.
The map shows that the active failure, a second bolus, depended on latent conditions created months earlier. When the electronic order set was introduced two years before, nobody removed the paper protocol, which pharmacy still printed and left at the bedside. The pump library allowed a bolus at any time without asking whether one had been given. The medication record displayed the bolus only by opening the infusion entry. Each of those decisions was reasonable in isolation.
| Work system part | Finding |
|---|---|
| Person | Day nurse floated from a surgical unit, unfamiliar with the protocol |
| Tasks | Bolus recorded inside the infusion entry, not as a separate dose |
| Tools | Paper protocol at bedside conflicted with the electronic order set |
| Environment | Handoff at a crowded station with frequent interruptions |
| Organization | Float nurses received no unit orientation; the paper protocol had never been retired |
SEIPS 2.0 and the Patient's Part
Holden et al. (2013) revised the model as SEIPS 2.0. The revision adds the external environment, such as regulation and vendor decisions, and divides the work into professional work, patient work and collaborative work, recognizing that patients and families do part of the work of care. It also separates outcomes that appear quickly from those that appear later and adds feedback loops through which a system adapts.
Seen through that lens, two more holes appear. The patient later said he told the day nurse he had already had the shot in his IV, but he was drowsy and she was not sure he understood. Collaborative work with the patient was not part of the handoff. The pharmacist reviewing the order at night verified the infusion but had no view of what was given from the pump, because the pump did not send data to the record. The vendor's interface would have allowed it, but the hospital had postponed that project for cost.
Recommendations Ranked by Strength
The team rated each fix by how far its success rests on someone's memory under pressure.
The team also recommended that the day nurse not be disciplined. She followed a protocol the hospital had given her, and the hospital's just culture policy treats an error caused by a system condition as a human error to be supported, not punished.
| Fix | Strength |
|---|---|
| Remove the paper protocol from pharmacy printing | Strong |
| Pump library requires confirmation that no bolus was given in the past 6 hours | Strong |
| Display the bolus as a separate entry in the medication record | Intermediate |
| Unit orientation checklist for float nurses, including high-alert drips | Weak |
| Ask the patient at handoff what medicines were given overnight | Weak |
Limits of the Review
The review relied on interviews held two weeks after the event, when memories had already been shaped by the first draft's conclusion, and the team could not watch a real handoff on the night in question. A systems model also makes it tempting to list every imperfection in the unit. The team kept its findings to conditions that plausibly contributed to this event and placed the rest on the unit's improvement list. Finally, strong fixes such as the pump change depend on a vendor update that may take months, so the weaker fixes carry the risk in the meantime.
Measures
The hospital will track the number of duplicate bolus alerts from the pump, heparin doses given outside the protocol, the share of float nurses completing unit orientation before their first shift and clotting results outside range within the first 12 hours of an infusion. The pump interface project will be reconsidered in the next budget cycle with this event as part of the case.
Conclusion
A review that ended with counseling would have left a paper protocol, a permissive pump and a hidden record entry in place. Reason's model explained why the first review stopped too early. SEIPS found the latent conditions in each part of the work system, and SEIPS 2.0 showed that the patient and the pharmacist were part of the work and part of the fix.
References
Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11), 1669-1686. https://doi.org/10.1080/00140139.2013.838643
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Reading the NUR 8420 Module 2 assignment instructions
Systems analysis is the first named concept in TESU's catalog description of NUR-8420, and since the course syllabus is not shared publicly, the second module is planned as a systems analysis of an adverse event. Plan on a DNP safety paper that describes one event factually, explains a recognized systems model, maps the event onto it to find latent conditions, recommends fixes ranked by how much they rely on human memory and sets measures that would show whether the fixes worked. Some sections supply a case from the textbook; others let students use a de-identified event from their own workplace. If you use a real event, strip every identifier and check the brief for a required model, such as SEIPS or a root cause analysis template.
How this NUR 8420 Module 2 example is built
Set on a telemetry unit, the invented heparin event at a Camden hospital opens the paper, followed by the first review's conclusion that the nurse should be counseled. Reason's contrast between person and system approaches explains why that review stopped early. The SEIPS model is described, and a five-row table maps the event onto person, tasks, tools, environment and organization. SEIPS 2.0 adds the patient's report and the pharmacist's blind spot. A ranked table of fixes follows, then measures and a conclusion. Two annotations explain why every row in the mapping table names a condition and why counseling does not appear among the fixes.
Where the marks sit in the NUR 8420 Module 2 rubric
Credit in a systems analysis paper goes to an accurate account of the chosen model, an event mapped onto it in enough detail to find conditions rather than culprits, fixes ranked by strength with the strongest addressing the latent conditions found and measures for each major fix. Mentors notice when a paper explains why the first explanation was incomplete. Treating the patient as a participant in the work, not only as the person harmed, reflects current thinking. Linking the treatment of staff to a just culture policy shows judgment. Model names and components should match the original authors, cited in APA style, and any event details from a real workplace should be stripped of identifiers.
Common NUR 8420 Module 2 mistakes, and how to avoid them
Many drafts end with education or a policy reminder as the main fix; aim for changes to tools and processes that work without anyone remembering. Another frequent gap is a systems model described in one section and never used in the next. Describe the event without blame words. Rank the fixes, and say why each sits where it does. Include the patient's role if the patient could have caught the error. Keep the patient's identity and the staff members' names out of every draft. The Camden review can guide yours, and a first draft built on your event and your brief costs nothing.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 8420 Module 2 questions, answered
Where can I find a free NUR 8420 Module 2 sample paper?
The systems analysis of an invented heparin event at a Camden hospital, from the first review to the ranked fixes, sits in full above.
What is the difference between active failures and latent conditions?
Active failures are the slips and wrong choices made while giving care; latent conditions are decisions made earlier, in design, management or written procedure, that leave openings for those acts to cause harm.
What are the parts of the SEIPS work system?
Five parts acting on one another: the individual, the job's tasks, the devices and software in use, the physical space and the organization around them.
What did SEIPS 2.0 add?
The external environment, a split of work into professional, patient and collaborative work, outcomes over time and feedback through which systems adapt.
Why is retraining a weak fix?
It depends on people remembering under pressure, while removing a hazard or forcing a check works no matter who is on shift.