Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

In the previous assessment, medication administration errors (MAEs) were linked to human and organizational factors. Regardless of the cause of MAEs and magnitude, their occurrence threatens care quality and patient safety directly or indirectly. However, without a systematic approach to the problem, the underlying root factors of medication administration errors may be left unresolved. A root-cause analysis (RCA) problem analysis process helps identify the root causes of issues to develop suitable solutions. This paper leverages the RCA method to analyze the root causes of MAEs in identified cases within a select hospital setting. It also presents evidence-based strategies applicable to address the causes of MAEs identified. It proposes an evidence-based improvement plan that can utilize the available organizational resources to reduce and prevent the occurrence of medication administration errors.

Analysis of the Root Cause

Medication administration errors are the primary and most common medical errors contributing to preventable patient harm. Medication administration mistakes can also result in adverse drug effects (ADEs), significantly impacting patients’ health and quality of life while also increasing the burden on the healthcare system. MAEs vary in magnitude and impact on patient safety and quality of care. Some medication administration errors may not cause harm to the patient, while others lead to ADEs and risk extreme outcomes, including death.

A root cause analysis was conducted by experts from the risk management department on 16 actual errors and 22 near-miss cases reported during the medication administration within the in-patient care settings across all departments in the hospital. The RCA aimed to understand the causes and underlying factors that contributed to errors and near-miss events in the in-patient care settings within the hospital. This information was utilized to select evidence-based strategies to improve the safety and quality of the medication administration process within the hospital and determine the resources needed for the improvement plan.

According to the RCA, 70 percent of the cases reported of actual medication administration errors were caused by nurses, while physician assistants caused 10, and 20 percent were related to patient mistakes. Also, 60 percent of the MAEs occurred during the night shift, while 40 percent occurred during the day shift. The MAEs occurring during the night shift had various contributing factors. The RCA identified that the nurses involved in 40 percent of the reported cases reported feeling worn out during the events after serving several patients due to the low number of nurses during the night shift. They also noted that in 20 percent of the cases, there were no pharmacists to consult on the medications provided, while five percent of the dosages entered on the patient bedside files were illegible. The RCA also noted that the names of the medicines to be administered were confusing in eight percent of the cases. Additionally, it was identified that cases involving the wrong dosage, wrong patients, and wrong delivery methods were due to 12 percent wrong dose calculation, seven percent wrong patient indicated, and eight percent confusion over the site shown on the medication.

The RCA also identified similar causes and underlying factors related to the errors occurring during the day shift. Additionally, the RCA noted that 30 percent of errors occurred due to distraction, 28 percent involved stress from high patient volumes during the day, and 12 percent involved patients moving during medication administration. In addition, 30 percent of the cases involved nurse students with limited experience in medication administration. The lack of collaboration between nurses and physician assistants was also identified as a root cause of 80 percent of the reported cases during the day and night shifts. Additionally, 80 percent of the near-miss instances were due to physicians and pharmacists doing ward rounds intervening during the medication administration, while 20 percent were after nurses consulted with other healthcare professionals during the administration process.

Application of Evidence-Based Strategies

Various evidence-based strategies can be applied within hospital settings and beyond to reduce and prevent the occurrence of MAEs. The safety of the medication process can be achieved by employing advanced multi-professional collaboration, improving communication effectiveness, and ensuring adequate skills during medication administration. Further, the safety of the medication process can be improved by implementing a systematic medication process and eliminating distractions from the work environment. Adopting a nursing curriculum that focuses on developing evidence-based competencies equips future nurses with the knowledge, attitudes, and skills to implement EBP in clinical practice (Hande et al., 2017). The Institute for Healthcare Improvement (n.d.) recommends a shift from focusing only on errors to including reducing harm as an essential aspect of patient safety.

Improvement Plan with Evidence-Based and Best-Practice Strategies

From the RCA, the leading causes of MAEs can be summarized as lack of professional collaboration, knowledge on medications, distractions, poor communication, and work pressure due to inadequate staffing. Therefore, the evidence-based improvement plan will employ strategies that improve interprofessional communication and collaboration, nurse knowledge of medication, and the work environment, including the staffing level. Galatzan (2019) suggested reducing miscommunication during shift hand-off and transfer of care as an essential approach to reducing medical errors in healthcare settings. Although Evidence-Based Practice (EBP) strategies utilize research and proven approaches to decision-making and solving problems and improve the quality and safety of care services, the efficiency of nurses to apply EBP is influenced by their readiness for EBP, EBP knowledge, attitudes, beliefs, skills, and the organizational culture (Rahmayanti et al., 2020). Therefore, the patient safety and care quality improvement plan will also focus on shifting the hospital toward adopting and normalizing an EBP culture.

Timeline of Development and Implementation

The improvement plan links evidence-based strategies with practices within medication administration. The plan will seek to ingrain safe practices during medication administration to improve care quality and ensure patient safety. The plan will be developed and implemented over eight months to achieve this. The first two-month phase will focus on educating the participants and creating awareness of MAEs and the best practices to reduce and prevent them. The next six months will focus on establishing the proposed evidence-based practices and evaluating the plan’s progress.

Existing Organizational Resources

The success of the improvement plan is leveraged on the available organizational resources. The resources necessary for the improvement plan to reduce and prevent MAEs and improve care quality and patient safety include a willing human resource, implementation of various technologies to support communication, nurse and physician training, and medication management.

The facility has an existing electronic health records (EHR) system, which requires upgrading. The nurses and physicians will be trained to use and integrate various communication channels across the in-patient facilities into their daily care operations. Healthcare professionals like pharmacists and senior medical officers are also willing to train nurses and physician assistants on safe medication administration.

Conclusion

Errors occurring during the administration of medications jeopardize care quality and patient safety. Identifying the active causes of medication administration errors can help design and implement evidence-based solutions to reduce and avoid such mistakes. An RCA can help identify the underlying causes of MAEs. However, regardless of the evidence-based and best-practice strategies implemented, their success is determined by the nurses’ and other involved parties’ knowledge, skills, and attitudes toward the EBP strategies. Organizational resources and plans should focus on supporting the implementation of the EBP strategies and stakeholder education and training on EBP strategies.

References

Galatzan, B. J. (2019). Exploring the content of the nurse-to-nurse change of shift hand-off communication (Publication No. 27666610) [Doctoral dissertation, University of Arizona]. http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2336369734%3Faccountid%3D27965

Hande, K., Williams, C. T., Robbins, H. M., & Christenbery, T. (2017). Leveling evidence-based practice across the nursing curriculum. The Journal for Nurse Practitioners, 13(1), e17–e22.

Institute for Healthcare Improvement. (n.d.). Why is reducing harm – not just error – important to patient safety? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/Bates-Reducing-Harm-Important-To-Patient-Safety.aspx

Rahmayanti, E. I., Kadar, K., & Saleh, A. (2020). Readiness, Barriers and Potential Strength of Nursing in Implementing Evidence-Based Practice. International Journal of Caring Sciences, 13(2), 1203–1211.

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You can use a supplied template for this assessment to conduct a root-cause analysis. The completed evaluation will be a scholarly paper focusing on a quality or safety issue about medication administration in a healthcare setting of your choice and a safety improvement plan.

Root-Cause Analysis and Safety Improvement Plan

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often, root-cause analyses are conducted, and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach to identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans and disseminate vital information to staff nurses and other healthcare professionals to protect patients and improve outcomes.

Completing the Quality and Safety Improvement Plan Knowledge Base activity and reviewing the various assessment resources would be an excellent choice as you prepare for this assessment. This will help you build your knowledge of critical concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Scenario
For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

The specific safety concern identified in your previous assessment about medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

Instructions
This assessment aims to demonstrate your understanding of and ability to analyze the root cause of a specific safety concern in a healthcare setting. You will create a plan to improve the safety of patients related to medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen healthcare setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, corresponding to the grading criteria in the scoring guide. Please study the scoring guide carefully to understand what is needed for a distinguished score.

Analyze the root cause of a patient safety issue or a specific sentinel event about medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issues or sentinel events about medication administration.
Create a feasible, evidence-based safety improvement plan for safe medication administration.
Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
Using the current APA style, communicate in clear, logical, and professional writing, with correct grammar and spelling.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like. However, remember that your Assessment 2 will focus on safe medication administration.

Demonstration of Proficiency
By completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event about medication administration. ;
Create a viable, evidence-based safety improvement plan for safe medication administration.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event about medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Using the current APA style, communicate in clear, logical, and professional writing, with correct grammar and spelling.
Professional Context
Nursing practice is governed by health care policies and procedures and state and national regulations developed to prevent problems. Nurses must participate in gathering and analyzing data to determine the causes of patient safety issues, solve problems, and implement quality improvements.