Root-Cause Analysis and Safety Improvement Plan
Medication administration errors remain one of the leading causes of avoidable injuries in the healthcare system. Sentinel events related to medication errors occur in several clinical settings. Incidences are especially higher where medications with narrow therapeutic indices are used, such as in the oncology clinic. This paper analyzes the root cause analysis of administration errors as a safety issue in medication administration. It also discusses strategies to address this issue and a safety plan for safe medication administration.
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Root Cause of Administration Errors
In an oncology clinic of a local healthcare facility, a sentinel event involving medication administration to a patient on chemotherapy was reported. The root cause analysis of the incident was instigated when a female patient aged 45 with breast cancer and on a paclitaxel regimen fell unconscious during chemotherapy. This was detected by the attending nurse. It was found that the drug was administered at a faster infusion rate than the recommended rate. The patient fell unconscious 30 minutes after the initiation of an infusion of the drug paclitaxel.
Analysis of the event revealed that the attending nurse committed an error while administering the medication to the patient and during the administration of pre-chemotherapy medications. She had misread instructions on administering the drug to that specific patient. Paclitaxel can be administered safely by 1-2-hour infusions (Ferrigno et al., 2021). In this specific case, the drug was supposed to run for two hours due to the patient’s vitals and attributes. In the above case, the attending nurse had set the infusion rate at 60 minutes. The nurse had also omitted a corticosteroid dose during pre-chemo.
Most chemotherapeutic drugs are administered sequentially. Premeds with a corticosteroid, an antihistamine, and an antacid precede the chemotherapeutic agent. This sequential administration is important since these drugs have narrow therapeutic indices, and adverse events are often apparent. Premeds and post-meds minimize these adverse effects and promote safety for the patients. In the case above, the nurse was found to have omitted an important premed applicable to paclitaxel use. Additionally, the nurse had committed an error while administering this medication.
Further investigations revealed several issues that may have contributed to the incidence. The nurse had committed an administration error by infusing the drug at the wrong infusion rate. The nurse was found to be experiencing burnout and accustomed to long shifts. She had just completed an 18-hour shift and was called upon to cover for another nurse who had had an emergency and could not report. Her poor mentation may be attributed to fatigue. Report findings also revealed a communication lapse between the pharmacist and the nurse. The pharmacists did not indicate the infusion rate for this specific patient. Communication between the pharmacist and the nurse plays a role in abating medication administration errors. This is because pharmacists have a vast knowledge of the pharmacokinetic properties of various chemotherapeutics agents. In this instance, the presence of pharmacists may have modified the trajectory of the outcomes. All these factors may have contributed to this sentinel event.
Application of Evidence-Based Strategies
Reports on etiologies of various administration errors have always pointed fingers at systemic issues as potential causes of administration errors. Healthcare systems and providers have been implicated in a majority of sentinel events in healthcare related to medication administration. Administration errors such as the wrong rate of administering intravenous medications, wrong route of administration, and administering medications to the wrong patient have been reported in various healthcare settings.
Several strategies can be used to reduce medication administrative issues. Electronic medical record systems and collaboration with pharmacists can help minimize administration errors (Mutair et al., 2021). Electronic medical records systems capture patient information and make it available to other caregivers. Nurses can use this information in making clinical decisions on the appropriateness of the medications and doses to be applied to the patient. Patient attributes that influence dosing and choice of medications that are captured by these systems include the patient’s vitals, other medications they are taking, and any comorbidities. This information is vital in medication administration. Involving pharmacists in medication administration can also help in minimizing errors. Pharmacists can provide accurate information on drug administration that may prevent medication errors. Nurse scheduling and staffing may also minimize errors attributable to nursing practice. Nurse scheduling and staffing reduce the workload on nurses and, therefore, enable them to operate optimally.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The improvement plan applicable in this case scenario utilizes two approaches: the first approach is to increase the effectiveness of nursing interventions in medication administration. This can be achieved by equipping nurses with basic education on drugs, such as pharmacokinetic parameters. Nursing staffing and scheduling may also be valuable in ensuring nurses operate optimally. Staffing offsets deficits in the nursing workforce while scheduling enhances operational efficiencies of the available nurses (Magalhães et al., 2019). Nurses’ effectiveness can also be enhanced by developing hospital policies that restrict nursing operational hours. Policies on operational hours seek to ensure nurses are only available for service during their scheduled times except during health emergencies. The goal of this approach is to eliminate errors resulting from nurses’ functional deficits. Another goal is to ensure oncology nurses have basic medication knowledge of the pharmacokinetic properties of various chemotherapeutic agents. The timeline of this plan ranges from two weeks to several months.
Another improvement plan approach targets enhancing nurses’ collaboration with the pharmacist and other caregivers. This can be achieved by educating the nurses on communication strategies utilized in healthcare communications. Additionally, policies requiring pharmacists’ presence during medication administration can be developed. Pharmacists play a vital role in medication administration. Their presence during the process can eliminate errors attributable to medication administration (Jaam et al., 2021). The goal of this approach is to minimize medication administration errors. The desirable outcome in this regard is a decrease in the incidence of medication errors occurring during drug administration. This plan can be developed and implemented in a few days.
Existing Organizational Resources
Existing organizational resources necessary in this regard include oncology nurses, pharmacists, and literature resources on medication handling and safety. Nurses play a role in administering chemotherapeutic medications. They are the cornerstone of these plans. Additional staffing may be necessary to augment the functionalities of the existing nurses. Pharmacists are also valuable due to their expertise in medications. Their knowledge can be vital in ensuring that medications are administered appropriately. Literature sources documenting the properties of drugs are also necessary. These resources may be in the form of journals, guidelines, and grey literature on medication administration. They provide valuable information on administering medications. Both existing nurses and pharmacists should be educated on the significance of collaborating to ensure the safe handling of medication as a quality enhancement initiative. Resources on the properties of individual drugs should also be made available to both nurses and pharmacists.
Conclusion
A safety improvement plan on medication administration errors targets addressing the root causes of administration errors. This is the first step toward enhancing the quality of care provision. Nurses remain central in this regard as they are involved in administering medications. Quality improvement measures on medication administration errors include enhancing nursing effectiveness in handling medication and collaborating with pharmacists. These measures may effectively reduce the incidence of medication administration errors.
References
Ferrigni, E., Grate, L., Herzog, T., Billingsley, C., & Jackson, A. (2021). Comparison of incidence of hypersensitivity reactions of paclitaxel infusions with titrated versus non-titrated infusions. Gynecologic Oncology, 162, S117-S118. https://doi.org/10.1016/s0090-8258(21)00865-9.
Jaam, M., Naseralallah, L., Hussain, T., & Pawluk, S. (2021). Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. PLOS ONE, 16(6), e0253588. https://doi.org/10.1371/journal.pone.0253588.
Magalhães, A., Kreling, A., Chaves, E., Pasin, S., & Castilho, B. (2019). Medication administration – nursing workload and patient safety in clinical wards. Revista Brasileira De Enfermagem, 72(1), 183-189. https://doi.org/10.1590/0034-7167-2018-0618.
Mutair, A., Alhumaid, S., Shamsan, A., Zaidi, A., Mohaini, M., & Al Mutairi, A. et al. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046
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Question 
For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as 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 for 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 as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which 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 successfully 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 pertaining to 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.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using the current APA style.
Professional Context
Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing 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 pertaining to 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
The purpose of this assessment is to demonstrate your understanding of and ability to analyze a 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 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 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.
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 current APA style.