Quality Improvement and Medication Errors
Why A Root Cause Analysis Was Appropriate for This Situation.
Medication errors are avoidable when the right systems are in place and when staff are trained on the importance of being keen. However, sometimes external factors can contribute to medication errors, such as nurse burnout, illegibility of labels, or miscommunication between the prescribing physician and the nurses, among others. In this case study, the pharmacist was keen to note that the dosage prescribed by the physician was high and took the necessary steps to ensure that the nurse administering the drug was aware of the amount that the patient required. However, the nurse, out of sheer habit, administered a higher medication dosage, resulting in the adverse event. Do you need urgent assignment help ? Get in touch with us at eminencepapers.com.
A root cause analysis can aid in repeating such an error in the future. A key area that would be analyzed in the root cause analysis would be the medication system that the hospital has in place. Analyzing the system will indicate where gaps exist and, in this case, the multiple medication entries that can and were wrongfully interpreted by the physician. Another area that would be highlighted would be the environmental factors that contributed to the medication error; in this case, the staffing numbers could have led to the nurse in question being overwhelmed, losing her concentration, and administering the drug out of habit or in a bid to finish up with the patient to get to the next patient. Lastly, a root cause analysis would reveal where communication errors occurred. Although the pharmacist identified the drug as being a high risk in its current dosage, he did not inform the physician. The pharmacist did not also tell the bedside nurse the reason why she had to administer the smaller dosage of 0.25ml; had he told her the adverse effects, she would probably be keener.
The Impact of Using Tools Like RCA, FMEA, And PDSA On the Quality and Safety of Patient Care.
Quality Improvement methods are used in healthcare to support the delivery of patient care of the highest quality and also improve patient outcomes. According to Charles et al. (2016), Root Cause Analysis is retrospective in nature as it seeks to identify the causal or basic factors that underlie performance variations that could lead to an adverse or sentinel event. An RCA asks the questions: what occurred, and why did it occur? It does not point at the person responsible but rather seeks to find out what caused the problem.
A Failure Mode and Effects Analysis, on the other hand, is prospective and aims at identifying any possible vulnerabilities and preventing future failures (Liu, 2019). FMEA speculates on what could go wrong and proposes measures to mitigate a failure. FMEA focuses on improving risky processes such as chemotherapy and blood transfusion, as well as other high-risk medications.
Using a PDSA cycle can help healthcare professionals deliver improvements in patient care via tests of change and an experimental structured approach to learning. The PDSA cycle facilitates organizational, team, and individual learning, thus making it a necessary tool in a healthcare facility. Christoff (2018) points out that the main aim of the PDSA cycle is the fast learning of how an identified intervention works and making the necessary adjustments to increase the possibility of delivering the desired improvement and sustaining the same or stop the proposed intervention altogether and pursue a different one that could possibly be more effective.
References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 1-5.
Christoff, P. (2018). Running PDSA cycles. Current problems in pediatric and adolescent health care, 48(8), 198-201.
Liu, H. C. (2019). Improved FMEA methods for proactive healthcare risk analysis (p. 15). Singapore: Springer.
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Question 
Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).
Complete the Root Cause Analysis Worksheet to analyze the case.
Multifactorial Medication Mishap Case Study:
Quality Improvement and Medication Errors
The Case A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty. The nurse informed the physician that the patient was having significant pain and that liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list — two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation).
At this hospital, the CPOE system listed each choice twice: one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product and ordered a 5-mg dose. All medication orders at the hospital had to be verified by a pharmacist. The pharmacist reviewing this order recognized that the higher concentration was atypical for inpatients but assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist verified the order and, to minimize the risk of error added a comment to both the electronic medication administration record (eMAR) and the patient-specific label that the volume to be given was 0.25 mL (5 mg). For added safety, the pharmacist personally retrieved, labeled, and delivered the drug and a calibrated syringe to the bedside nurse to clarify that this was a high-concentration formulation for which the volume to administer was 0.25 mL (a smaller volume than would typically be delivered).
Multifactorial medication mishap
Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she was more used to give, and then left for her break. A covering nurse checked on the patient and found him unconscious — a code blue was called. The patient was given naloxone (an agent that reverses the effect of opioids), and he responded well. He was transferred to the intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the effect of the oxycodone. By the following morning, the patient had returned to his baseline with no apparent adverse effects.
Write a 525 word-summary in which you:
Explain why a root cause analysis was appropriate for this situation.
Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.
Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.