NURS FPX4020 Capella Root Cause Analysis and Safety Improvement Plan

NURS FPX4020 Capella Root Cause Analysis and Safety Improvement Plan

Medication errors have been a major safety concern in the healthcare system for decades. These errors have been linked to a variety of negative outcomes, including longer hospital stays, readmissions, and death. As a result, addressing the issue of medication error is critical to improving patient and health outcomes. A root cause analysis is critical in identifying the primary causes of the problem, which guides the development of an evidence-based plan to address the issue. The root cause analysis is critical in allowing healthcare professionals to investigate the issue of medication error and define a solution. A root-cause analysis is performed for this review to investigate a medical error case, apply evidence-based strategies to address the issue and develop an improvement plan using organizational resources.

Root-Cause Analysis

Event Description 

In practice, nurses play a variety of roles in promoting the delivery of healthcare services to meet the needs of patients. Nurses play a role in medication prescription and administration. During routine practice, a 68-year-old man was given Novasone scalp lotion in his right eye by mistake. The lotion was misidentified as a lubricating eye drop stored in a container of similar size and shape. The patient immediately recognized the error, feeling a burning sensation, pain, and discomfort in his eye. The resident reported that the eye drop was given to him by mistake, and once the problem was identified, the attending nurse immediately washed the resident’s eye with saline. The general physician was contacted and advised on the continued use of saline.

Analysis and Key Findings

A root-cause analysis assists in exploring potential causes of a problem and narrowing it down to the exact cause of the problem, as well as developing a plan to address the issue. Medication errors can occur at various levels, and as Zhou et al. (2017) describe, these errors can cause unintended harm to the patient. In most cases, nurses collaborate with physicians to ensure that patients receive the necessary care, including medication administration. While the service nurse administered the Novasone, the problem stemmed from dispensing rather than administration. The drug was incorrectly dispensed to the patient, and the nurse was involved in the administration. As a result, there was a problem with the supplier pharmacy, which used the same drug packaging and labeling. The charge nurse at the facility did not review the drug, which amounted to gross misconduct and resulted in a medication administration error. Other than discomfort and self-limiting pain in the eye, there was no major harm to the patient as a result of the medication’s adverse effect in this case.

Several issues would have been addressed in order to improve the outcomes and avoid errors. Proper labeling and packaging of the medication to avoid confusion during administration is one possible action that would have prevented the error. The supplier pharmacy would have completed the action because the same packaging and labeling had been used for two different products, resulting in incorrect use. Another action that could have prevented the error is a medication review prior to administration; charge nurses are responsible for reviewing medications before administering them. Tariq et al. (2020) state that vigilant medication review is critical in preventing medication errors. Because nurses and doctors are primary care providers, they must thoroughly review medications before administering them. As a result, the supplier pharmacy did not follow proper labeling procedures, and the facility’s healthcare professionals did not review medications before administering them.

Evidently, there was an interaction of human and communication factors that aided the issue. There was no clear communication between the supplier pharmacy and the healthcare organization about the labeling and packaging of the medications, which increased the risk of incorrect drug administration. Poor communication between the pharmacy and the healthcare providers could have exacerbated the problem. Furthermore, human factors such as a lack of collaboration may have contributed to the problem, as it involves both the dispensing (pharmacy) and administration (healthcare providers) aspects of medication errors.

The Use of Evidence-Based Strategies

Medication error prevention is one approach to improving the safety of healthcare services. Medication errors do occur; however, the extent to which they occur can be reduced through a variety of methods (Tariq et al., 2020). Medication errors can be caused by a variety of factors. Key risk factors for medication errors, according to Tariq et al. (2020), include a lack of follow-up, poor handwriting, poor communication, interpersonal factors, and shift work. Preventing or minimizing the specific consequences of these risk factors is critical to achieving the desired results. Poor communication and human error/factors were key factors in this case that led to the error. When it comes to improving medication safety, encouraging effective drug monitoring and review is critical. A review, according to Tariq et al. (2020), will assist healthcare providers in delivering the correct dosage as well as identifying drug contraindications and interactions, which are major determinants of safety outcomes. Poor communication, on the other hand, increases the risk of miscommunication, which reduces the quality of healthcare services because healthcare professionals may work with incomplete information. Tariq et al. (2020) state that poor communication is one of the major risk factors for medication errors.

Many approaches are used to prevent medication dispensing and administration errors, depending on the potential causes and risk factors. For example, Naunton et al. (2016) recommend that healthcare professionals focus on reading drug labels to ensure that the patient receives the correct medication. The study also suggests that pharmacists involved in the study label drug containers properly, especially for monocular medicine that comes with dropper bottlers, to avoid potential confusion during administration (Naunton et al., 2016). Other preventive measures may be implemented to improve medication administration and dispensing. Goedecke et al. (2016) recommend a life-cycle prevention approach that addresses all types of medication errors, from the time the drug is manufactured to the time it is administered to the patient. Tariq et al. (2020) identified medication rechecking, consulting pharmacists about a drug, and signing a prescription based on this approach. Mieiro et al. (2016), on the other hand, suggest that educational strategies for healthcare professionals, organizational strategies, and technology use may help reduce prescription, dispensing, and administration errors. A combination of these strategies may produce the best results in terms of medication error prevention and mitigation.

Plan for Improvement Using Evidence-Based and Best-Practice Strategies

Medication administration is critical for influencing patient health outcomes and determining an organization’s level of safety. The error, as stated in the case, was caused by a lack of proper communication between the healthcare provider and the pharmacists, as well as a lack of medication review prior to administration. As a result, an improvement strategy should emphasize improved communication and employee accountability for their actions. As a result, the plan is to create a comprehensive communication framework supported by the hospital’s information management system to facilitate productive interprofessional collaboration among healthcare professionals, including pharmacists, and to create a drug review protocol for all facility administrators. As identified by Tariq et al. (2020), communication is critical in influencing medication errors. Because administration errors can result from dispensing errors, enabling effective communication between the pharmacy and healthcare professionals is critical in minimizing errors.

A medication review protocol may also be useful in preventing administration errors. According to Doyle and McCutcheon (2015), such a plan would be effective if the seven medication rights were followed, which include the right patient, drug, route, dose, time, reason, and documentation. Medication errors like the one, in this case, occur as a result of the physician’s poor reference and review of the drug prior to administration, which are common causes of incorrect drug use. Outlining a clear procedure to ensure that physicians and nurses review medication and refer to up-to-date patient information is therefore critical in preventing administration errors. The goal of the two interventions is to reduce both unintended and intended medication errors by focusing on pharmacy and physician actions and inactions. The plan will be completed in three weeks to achieve this goal, as outlined below:

Week 1: Create a comprehensive communication plan for healthcare as well as a drug review protocol.

Week 2 – train employees on the new medication review protocol and introduce them to the new communication channel to make implementation and achievement of stated objectives easier.

Week 3 – Put the plans into action and assess their effectiveness while strengthening them.

The plan would be developed and effectively implemented using the aforementioned approach to minimize and prevent medication administration errors.

Existing Organizational Asset

The plan’s implementation will require a multidisciplinary team rather than a single soldier. As a result, human resources, or the organization’s staff, are the primary resource. To avoid employee resistance to change, it is best to collaborate with healthcare employees to investigate the problem, identify potential solutions, and implement the best solution.

Another critical resource is the organization’s information management system, which will serve as the foundation for effective and timely communication among healthcare professionals. A communication framework will be developed and integrated using the organization’s information management system to promote safety in information flow and, thus, medication administration. It is also critical to acknowledge the value of the quality assurance committee as a resource. The quality assurance committee is responsible for the implementation and monitoring of quality issues, including medication review, when developing the medication review protocol. As a result, this will be a valuable resource in carrying out the identified plan.

Conclusion

Medication errors are common in the healthcare setting and can have serious consequences for the patient. The case involved a medication administration that was caused by confusion caused by medication labeling and storage containers. The error was caused by poor communication and a lack of physician review of medication prior to administration, as evidenced. A comprehensive communication strategy and medication review protocol have been identified as important in minimizing and preventing similar errors within the organization in light of these issues. Implementing the proposed plan could effectively prevent medication errors at all levels of practice by utilizing human resources, a quality assurance committee, and an interprofessional team.

References

Doyle, G. R., & McCutcheon, J. A. (2015). Clinical procedures for safer patient care. BC Open Textbook Project. https://opentextbc.ca/clinicalskills/front-matter/about-the-book/

Goedecke, T., Ord, K., Newbould, V., Brosch, S., & Arlett, P. (2016). Medication errors: new EU good practice guide on risk minimization and error prevention. Drug safety, 39(6), 491- 500. https://doi.org/10.1007/s40264-016-0410-4

Mieiro, D. B., Oliveira, É. B. C. D., Fonseca, R. E. P. D., Mininel, V. A., Zem-Mascarenhas, S. H., & Machado, R. C. (2019). Strategies to minimize medication errors in emergency units: an integrative review. Revista brasileira de enfermagem, 72, 307-314. https://doi.org/10.1590/0034-7167-2017-0658

Naunton, M., Nor, K., Bartholomaeus, A., Thomas, J., & Kosari, S. (2016). Case report of a medication error: In the eye of the beholder. Medicine, 95(28), e4186. https://doi.org/10.1097/MD.0000000000004186

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Tariq, R., Vashisht, R., Sinha, A., & Scherbak, Y. (2020). Medication dispensing errors and prevention. IN StatPearls [Internet]. Treasure Island (FL). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Zhou, S., Kang, H., Yao, B., & Gong, Y. (2018). Analyzing medication error reports in clinical settings: an automated pipeline approach. In AMIA Annual Symposium Proceedings (Vol. 2018, p. 1611). American Medical Informatics Association. Https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371341/

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This assessment aims to demonstrate your understanding of and ability to analyze the root cause of a specific safety concern in a healthcare setting. Based on the results of your analysis, you will create a plan to improve the safety of patients related to medication administration safety. You will use the literature, professional best practices, and 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 to 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, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you 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.
• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using the current APA style.

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 but keep in mind that your Assessment 2 will focus on safe medication administration.

• Assessment 2 Example [PDF].

Additional Requirements

• Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a      4–6 page root-cause analysis and safety improvement plan pertaining to medication administration.
• A number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: Format references and citations according to the current APA style.