NURS 4220 – Week 4 Practice Experience Discussion – Developing the Quality Improvement Plan
Root cause analysis (RCA) plays a crucial role in quality improvement. RCA is a structured method used to identify factors that cause an unfavourable outcome. The Joint Commission requires an RCA for all sentinel events, an event that severe harm or death occurs. The Joint Commission encourages an RCA to be complete when a near miss occurs. A near miss is defined as an event that did not result in death or injury but could have. (Spath, 2018, pp. 211). RCA occurs directly after a sentinel or near-miss event and involves a group of highly educated people to assist in the investigation. The RCA team will collect and analyze data in hopes of identifying how and why the event occurred. RCA’s goal is to prevent unfortunate events in the future by eliminating the errors that led up to the event (Agency for Healthcare Research and Quality, 2019). Hire our assignment writing services in case your assignment is devastating you. We offer assignment help with high professionalism.
At the beginning of the video, the team’s collaboration amongst each other was weak. The staff nurse immediately placed the blame on the pharmacy tech for the eight medication errors experienced for the month. The nurse’s body language displayed disgust and disappointment while she pointed fingers at the pharmacy tech. Luckily, with the help of the Quality Assurance Manager (QA), the discussion got back on track to find the root cause of the medication errors. A common concern expressed by both the staff nurse and the pharmacy tech was staffing issues. The QA manager was receptive to their concerns, but again she was able to take the lead and guide the conversation towards the RCA. The nurse and the pharmacy tech can provide ideas towards what could cause medication errors from their viewpoints, considering their jobs are different. Yet, both are involved in patient care and medication administration. The teamwork improved once the pharmacy tech and nurse agreed to help the QA manager use a flow chart, cause and effect diagram, medication error analysis and scheduled weekly meetings to discuss further and evaluate the performance.
The RCA team utilized three performance tools to assist in the evaluation of performance. The three tools used included the flow chart, cause and effect diagram, and the Pareto chart (Laureate Education, 2016). Each of these tools is beneficial, but the Pareto chart seems to be the better choice for this scenario. The Pareto chart is like the bar graph, but the data is sorted by the most frequent cause of the problem and then the next most frequent and so on (Spath, 2018, pp. 92). Looking at the Pareto chart given for the scenario, it is evident that the most frequent causes of medication errors are defective scanners, look, medications, and pharmacy tech stress/error. Providing rationales for the cause of the problem can better assist the RCA team in developing and implementing a plan to decrease the incidence of future mistakes.
NURS 4220 – Week 4 Practice Experience Discussion – Developing the Quality Improvement Plan
Medication errors remain the most common medical error in healthcare facilities. Factors contributing to medication errors can include the nurses not following the seven rights to medication administration, including the right patient, right medication, the right dose, right time, right route, right reason, and right documentation (British Columbia College of Nursing, n.d.). Other factors that can contribute to medication errors are the physician prescribing the wrong medication or medication dose, pharmacy error in dispensing the medication, and technical errors such as defective scanners and barcodes.
Medication errors are preventable. With the help of the RCA, the identification of the causes can assist team members in constructing a plan for change to decrease the prevalence of medication errors. Playing the “blame game” does not consider why an adverse event occurred and fails to address the root cause analysis, which is crucial for preventing future events (Hughes & Ortiz, 2005, p. 20).
References
Agency for Healthcare Research and Quality. (2019, September 8). Root Cause Analysis. PSNet. https://psnet.ahrq.gov/primer/root-cause-analysis
British Columbia College of Nursing. (n.d.). Medication Administration. BCCNP. Retrieved August 4, 2020, from https://www.bccnp.ca/Standards/RN_NP/PracticeStandards/Pages/medicationadm in.aspx#:%7E:text=Principles%20%20%201.%20%20%20Nurses%20are,can %20a%20…%20%207%20more%20rows%20
Hughes, R. G., & Ortiz, E. (2005). Medication Errors. Journal of Infusion Nursing, 105(Med Safety), 14–24. https://doi.org/10.1097/00129804-200503001-00005
Laureate Education (Producer). (2016). Root cause analysis at Downtown Medical. [Interactive file].
Baltimore, MD: Author.
Spath, P. (2018). Introduction to Healthcare Quality Management (3rd ed.). Health Administration Press, Chicago, IL.
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Question 
NURS 4220 – Week 4 Practice Experience Discussion – Developing the Quality Improvement Plan
By Day 4, post a description of some of the proposed action steps for implementing improved practice and explain
where potential challenges might compromise your proposed improvement project. Describe what resources are needed
for your solution, and explain whether or not those resources are cost-effective. Continue to collaborate with the selected
individuals in your practice environment as needed in the development of the practicum project, and share this information with your group.