Root-Cause Analysis and Safety Improvement Plan-Improper Dosing

Root cause analysis is a systematic process of discovering the root causes of a problem using a wide range of techniques to identify possible address interventions. Root cause analysis of improper dosing and other medication-related errors seeks to discover various causal factors and identify possible solutions. A root cause analysis of improper dosing was conducted at the ED of a Diabetic clinic. This paper analyzes improper dosing, as a safety issue, with emphasis on the root causes, evidence-based strategies to address them, safety improvement plans for improper dosing, and the organizational resources that can be leveraged to ensure safe medication administration.

Root Cause Analysis of Improper Dosing

Improper dosing may be in the form of extra dosing, underdose, or overdose. Cavell & Mandaliya (2019) defines improper dosing as an event that occurs when a patient is given a medication with an inappropriate dose, a dose different from what was ordered, or through the wrong route of administration. Improper dosing can result in serious health complications. Organ damage, allergic reactions, and even death may arise when drugs are administered in incorrect doses. Whenever they occur, improper dosing prolongs hospital stay days for patients, increases the rate of hospital admission and readmission, and lowers the quality of life of an individual. The resultant healthcare burden underpins the need to address them.

The root cause analysis was conducted at the ED of a diabetic clinic after a diabetic patient developed severe hypoglycemia with resultant seizures and confusion after being given insulin. The lead nurse detected this problem and initiated corrective measures for the patient. This problem involved a nurse intern and a nurse on rotation at the clinic. The hospital’s medical team, consisting of a pharmacist, a physician, and the lead nurse, conducted the analysis.

Analysis of the event revealed that the insulin was administered via the wrong route. While the prescription order indicated that the insulin was to be given through a subcutaneous route, the nurse administered the drug intravenously. The wrong route of administration is a causal factor for improper dosing. Several influences were implicated as causal factors for the nursing error that led to the event. Inexperienced staff, fragmented communication, fatigue attributable to the high volume of patients, and shift work were all implicated in the event. Inexperienced staff is a risk factor for nurse-related medication administration errors. Dehvan et al. (2021) report that the prevalence of medication errors among nursing students remains high. This is attributable to their little experience and inadequate knowledge of medications.

Fragmented communication between caregivers is another risk factor for medication administration errors. There was evidence of fragmented communication between the intern nurse, the pharmacists, and the nurse in charge. Communication gaps in healthcare impede information sharing and discourage constructive consultations that may help in the prevention of medical and medication errors. Up to 27% of medical malpractices are a consequence of fragmented communication and communication failures (Tiwary et al., 2019). This highlights the need for better communication.

Fatigue attributed to a high volume of patients and tight work shifts also plays a role in this case. The nurse reported doing double shifts to cover up for an earlier missed shift. Fatigue and nurse burnout attributable to high workload are causal factors for many nursing mistakes. Burnout is a significant predictor of medication administration errors (Aryankhesal et al., 2019). This highlights the need for staff rescheduling and staff addition as measures for lessening workload.

Application of Evidence-Based Strategies

Enhancing nurses’ experiences and knowledge of medication administration maintains effectiveness in lowering nurse-related medication errors. This can be attained systematically by increasing the duration of supervised contact between nurse students and the patients and expanding nurses’ training on medication. Mohammadipour et al. (2020) assert that blended learning remains an effective strategy for enhancing nurses’ knowledge of medication. This intervention can enhance nurse experience and knowledge of medications, lowering their likelihood of making errors.

Minimizing nursing fatigue and burnout can also help in reducing medication-related errors. This can be achieved through nurses rescheduling and improving the nurse-patient ratio to lower the workload on individual nurses, improving communication skills, encouraging teamwork and partnerships, and implementing support programs that help nurses cope with pressure (Aryankhesal et al., 2019). These interventions can be used to lessen fatigue which contributes to nursing mistakes and errors. Fostering healthcare communication may also minimize medication-related errors (Tiwary et al., 2019). Nurses should, thus, be educated on communication skills to enhance their communication processes. This may enhance their capacity to consult with other nurses, helping them avoid avoidable mistakes.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan for the healthcare setting under scrutiny will utilize educative and administrative approaches to implement the plan. The main goal of educative approaches is to expand nurses’ experience and knowledge of medication administration, while administrative approaches seek to address nursing fatigue and burnout. Educative programs will be administered through in-job training, which will be available weekly to all nurses. Aspects of practice that will form the bulk of these training sessions include communication skills for nurses, nursing collaborations in healthcare, medication handling, and interventions to minimize nurse-related medication errors (Mohammadipour et al., 2020). These pieces of training are expected to widen nurses’ understanding of their role in medication administration. The training is expected to achieve its goals within 7-10 weeks.

Administrative approaches will include staff rescheduling and the institution of participatory programs and support programs to help nurses cope with clinical difficulties. Staff rescheduling assigns nurses to their roles based on their experience and patient acuity. It minimizes fatigue and burnout by restricting the number of patients nurses handle (Groves et al., 2020). Supportive programs such as psychosocial interventions may ease nurses’ tension and provide the much-needed relaxation required for optimal cognitive functioning. Implementing these corrective measures may lower nurses’ burnout and optimize their care provision processes. This intervention is expected to achieve its goals in 1-3 months.

Existing Organizational Resources

Several existing organizational resources can be leveraged to minimize medication-related errors. These include educational resources on medication administration, such as literature, textbooks, drug leaflets, and online resources on medication handling. This may be used to expand nurses’ knowledge of medication handling administration. The mental health department is another valuable resource that can help nurses cope with clinical complexities and psychosocial challenges contributing to their fatigue and burnout. Leveraging these resources for nurses may help them prevent avoidable mistakes during medication handling.

Conclusion

Root cause analysis maintains significance in discovering root causes of care issues in healthcare and provides the groundwork for addressing them. As evident in the case above, root cause analysis informed evidence-based strategies to address improper dosing, such as staff training. These strategies can be integrated into an improvement plan to minimize medication errors. Organizational resources can be leveraged to complement the improvement plan and ensure it attains its target.

References

Aryankhesal, A., Mohammadibakhsh, R., Hamidi, Y., Alidoost, S., Behzadifar, M., Sohrabi, R., & Farhadi, Z. (2019). Interventions on reducing burnout in physicians and nurses: A systematic review. Medical Journal of The Islamic Republic of Iran. https://doi.org/10.47176/mjiri.33.77

Cavell, G. F., & Mandaliya, D. (2019). The magnitude of error: A review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system. European Journal of Hospital Pharmacy, 28(5), 260–265. https://doi.org/10.1136/ejhpharm-2019-001987

Dehvan, F., Dehkordi, A. H., Gheshlagh, R. G., & Kurdi, A. (2021). The Prevalence of Medication Errors Among Nursing Students: A Systematic and Meta-analysis Study. International journal of preventive medicine, 12, 21. https://doi.org/10.4103/ijpvm.IJPVM_418_19

Groves, P. S., Farag, A., & Bunch, J. L. (2020). Strategies for and barriers to fatigue management among acute care nurses. Journal of Nursing Regulation, 11(2), 36–43. https://doi.org/10.1016/s2155-8256(20)30108-3

Mohammadipour, F., Farzi, K., Toulabi, T., Heidarizadeh, K., & Heydari, F. (2020). The effect of blended learning on the rate of medication administration errors of nurses in medical wards. Iranian Journal of Nursing and Midwifery Research, 25(6), 527. https://doi.org/10.4103/ijnmr.ijnmr_188_20

Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: Examples from two case reports. Wellcome Open Research, 4, 7. https://doi.org/10.12688/wellcomeopenres.15042.1.

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Question

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

Root-Cause Analysis and Safety Improvement Plan-Improper Dosing

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 key 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.

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 pertaining to medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify existing 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.

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 the concern of 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 pertaining to medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to 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, keep in mind that your Assessment 2 will focus on safe medication administration.

Root-Cause Analysis and Safety Improvement Plan-Improper Dosing