| Course | NR 529 Leadership and Management within the Clinical Healthcare Environment |
|---|---|
| Week | 6 |
| Paper type | Incident follow-up memo |
| Length | About 1,040 words, 2 pages |
| Format | Memo with APA 7 citations |
| School | Chamberlain University |
| Program | MSN, Nurse Executive |
| Updated | September 2026 |
Free sample paper for NR 529 Week 6
Memorandum
To: All registered nurses, patient care technicians and unit clerks, Renal and Urology Medical Unit
From: Student Name, RN, Nurse Manager
Date: Month Day, Year
Re: Follow-up on Thursday night's dialysis access event: findings, three changes from Monday and what is not changing
Why You Are Getting This
Most of you heard on Friday morning that a patient on our unit lost the use of his dialysis fistula after it was used for a blood draw and a blood pressure cuff. I promised at huddle that you would get a written account once we understood what happened. This memo is that account. It does not name the patient or anyone involved, and it is not a disciplinary document. Please read it before your next shift, and bring questions to me or to your charge nurse.
What Happened
The patient, who has an arteriovenous fistula in his left forearm, was admitted on Wednesday afternoon with pneumonia. At admission he had a red limb alert band on his left wrist, and his admission nurse documented "left arm fistula, no BP, no sticks." On Wednesday evening his right-arm intravenous line failed. The nurse who restarted it placed the new line in his right hand and, to reach the vein, moved his band. The band was later found in the bed linen.
At 0400 on Thursday, a laboratory phlebotomist came for the morning draw. The patient was drowsy, the right hand had the new line, and the phlebotomist drew blood from the left forearm. At 0600, the automatic blood pressure cuff, which had been moved to the left arm after the line restart, cycled for the routine check. At 0730 the day nurse could not feel the thrill over the fistula. Interventional radiology attempted to clear it that afternoon without success. The patient had a temporary dialysis catheter placed on Friday and will need a new access. He and his family have been told what happened, and the patient safety office has the full report.
What We Found
The review on Friday and Monday found no single mistake that explains the event. It found four small gaps that lined up.
The band was the only signal. Once it came off, nothing else in the room told a new person which arm to protect. The whiteboard did not mention the fistula, and there was no sign above the bed.
Nobody owned putting the band back. Our line restart practice says nothing about limb bands, so the nurse who moved it had no prompt to replace it, and night handoff did not include a check of the arms.
The cuff moved with the line. The monitor cuff was placed on whichever arm was free, which after the restart was the fistula arm.
Phlebotomy relied on the patient. The phlebotomist asked the patient which arm to use. A drowsy patient at 0400 is not a reliable safeguard.
National guidance treats the protection of an established access, and of arm veins in people with kidney disease, as part of access care rather than an afterthought (Lok et al., 2020). Our practice depended on one band staying on one wrist.
What Changes on Monday
1. A sign and the whiteboard. Every patient with a fistula or graft will have a laminated sign above the bed reading "Left (or right) arm: dialysis access. No blood pressure, no needles," and the access arm will be written on the whiteboard. The admitting nurse places both. Signs are in the clerk's drawer.
2. Arms at handoff. At every shift handoff, the outgoing and incoming nurses will check the band and the sign together at the bedside for each patient with an access. This adds under a minute per patient. If a band is missing, it is replaced before the outgoing nurse leaves.
3. The cuff arm. For patients with an access, the monitor cuff goes on the leg if the other arm is unavailable. The charge nurse will stock thigh cuffs in the clean utility room.
The laboratory's phlebotomy lead has agreed separately that phlebotomists will check the sign and whiteboard before any draw and will not rely on the patient's answer alone.
What We Are Deliberately Leaving Alone
Some changes were suggested and are not being made, and I want to explain why.
No new form. A new access checklist in the record was suggested. We already document the access at admission; the gap was in the room, not the chart. A form would add work without adding a signal.
No change to intravenous restart practice. The nurse who restarted the line did so correctly and quickly. The change is the handoff check, which catches a missing band whatever the reason it came off.
No individual discipline. The review found system gaps and reasonable actions by each person involved. Nobody is being written up. If you were on shift that night, you did not cause this on your own, and you should not carry it on your own either.
No new band supplier. The band did not fail. It was moved. A stronger band would not have helped.
For the Staff Who Were There
Clinicians involved in events that harm a patient often feel guilt, doubt and fear for weeks afterward, and many do not tell anyone (Wu, 2000). Researchers who followed staff after such events describe a recovery that can stall without support from colleagues and leaders (Scott et al., 2009). Our peer support team can be reached through the house supervisor at any hour, and I am available to talk privately. I would also ask everyone else on the unit to keep conversation about this event to what helps us change practice, not who was on shift.
What Happens Next
I will audit the signs and handoff checks on every patient with an access for four weeks and share the results at huddle. If the checks are not happening, I will ask why before I ask anyone to do them harder. The patient safety office will share its final report within 30 days, and I will circulate its findings to you. Thank you to the day nurse who found the problem at 0730 and escalated it at once, and to everyone who has already suggested improvements.
References
Lok, C. E., Huber, T. S., Lee, T., Shenoy, S., Yevzlin, A. S., Abreo, K., Allon, M., Asif, A., Astor, B. C., Glickman, M. H., Graham, J., Moist, L. M., Rajan, D. K., Roberts, C., Vachharajani, T. J., & Valentini, R. P. (2020). KDOQI clinical practice guideline for vascular access: 2019 update. American Journal of Kidney Diseases, 75(4, Suppl. 2), S1-S164. https://doi.org/10.1053/j.ajkd.2019.12.001
Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Brandt, J., & Hall, L. W. (2009). The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Quality and Safety in Health Care, 18(5), 325-330. https://doi.org/10.1136/qshc.2009.032870
Wu, A. W. (2000). Medical error: The second victim. BMJ, 320(7237), 726-727. https://doi.org/10.1136/bmj.320.7237.726
Reading the NR 529 Week 6 instructions
The Week 6 assignment usually asks for a written communication to staff after an incident or near miss, such as a memo or unit update. Prompts ask for a factual account, the causes identified, actions being taken, support for staff and a professional tone that avoids blame. Write for the nurses and technicians who were on shift and already know something happened. Give the facts in order without names, explain what the review found, state what will change and when, and say what will not change and why. Include support for staff affected by the event. Link your approach to patient safety or just culture sources in APA 7, and use memo format with a clear subject line.
How this NR 529 Week 6 example is built
The memo opens by explaining why staff are receiving it and that it is not disciplinary. A factual section follows the patient from admission with a limb band through the line restart, the 0400 blood draw, the 0600 cuff cycle and the lost thrill at 0730, ending with what the patient was told. The findings list four gaps: the band as the only signal, no owner for replacing it, the cuff following the free arm and phlebotomy relying on a drowsy patient. Three changes are stated with who does what. A section explains what is being left alone, including a new form and discipline. The memo closes with support for staff involved, citing second victim research, and a four-week audit.
Where the points sit in the NR 529 Week 6 rubric
Memo rubrics for this week generally reward an accurate and objective account, clear identification of contributing factors, specific corrective actions, attention to staff support and appropriate format and tone. Graders favor memos that explain what happened without assigning blame to individuals. Findings described as system gaps, each linked to a change, show analysis. Stating what will not change often earns credit because it shows judgment and prevents rumors. Staff support backed by evidence on the effects of adverse events on clinicians demonstrates leadership. Memo format, a subject line that states the purpose and a length staff will read count toward communication. Sources belong in APA 7 at the end.
Common NR 529 Week 6 mistakes, and how to avoid them
The biggest problem in these memos is blame, stated or implied, which teaches staff to hide the next event. Describe actions and gaps, not people. Another is a memo that is mostly apology or feeling and never says what changes. Staff want to know what Monday looks like. Students also list many changes without saying who does each one. Keep changes few and specific. Avoid clinical detail that identifies the patient. Do not promise outcomes you cannot guarantee. Forgetting the staff who were involved is a common gap; tell them where support is. Finally, say how you will check that the changes happen, since a memo without follow-up is easy to read and forget.
Get a NR 529 Week 6 example written to your instructions
Send the scenario your section published, the memo template if there is one, and the rubric, and we will write a custom NR 529 follow-up memo built to that format and that event. It is written to your instructions only, the first one is free, and it reaches you inside 24-48h.
More NR 529 papers and MSN samples
- NR 529 Week 1: Discussion on Refusing a Request
- NR 529 Week 2: Delegation Analysis of a Standing Job
- NR 529 Week 3: Staffing Assignment Rationale
- NR 529 Week 4: Coaching Conversation Plan
- NR 529 Week 5: Unit Budget Review
- NR 529 Week 7: Retention Plan
- NR 529 Week 8: Management Philosophy Statement
NR 529 Week 6 questions, answered
Can I write about something that really happened at work?
Yes, with everything identifying removed and the clinical detail reduced to what the memo needs. An actual incident report, a safety file entry or a patient record stays with your employer and does not travel into coursework. Most students change the unit type, the timing and the order of events enough that it is unrecognisable while the management problem underneath stays intact.
Should the memo apologize?
A short acknowledgment that something went wrong is fine and often reads well. What does not work is a memo whose main content is regret, because staff have already had the feelings and are waiting to hear what happens now. Keep any apology to a sentence, put it near the top, and spend the rest of the page on the change.
How does this differ from a root cause analysis?
Length and audience, mostly. A full analysis is a formal document produced by a team and read by a committee; this memo is one manager telling a unit what was learned and what alters on Monday. If your section asks for both, keep the analytic work in the analysis and let the memo carry only the parts staff need in order to work differently.
Where can I find a free NR 529 Week 6 sample paper?
This page carries the dialysis access follow-up memo, the complete NR 529 Week 6 sample, open for anyone to read without charge. If your incident was different, give us the outline in the request form and a memo written for your unit can be prepared.
Should the NR 529 incident memo name the staff involved?
No. The memo is for the whole unit, and naming staff turns it into a disciplinary notice. The sample describes each action by role and time and states plainly that nobody is being written up.