Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

A majority of adverse drug events (ADEs) are due to errors in medication administration. ADEs are preventable; however, they remain an issue of concern in nursing and other care settings. Multiple factors can contribute to a single or multiple ADEs. A comprehensive analysis of the ADEs is required to determine their root causes and provide long-term solutions and interventions. This paper will apply the root-cause analysis (RCA) technique to analyze the root causes of an ADE issue related to a diabetic patient. It will also apply evidence-based strategies to address the ADEs as a safety issue in medication administration. In addition, it will also describe a safety improvement plan designed to prevent the reoccurrence of the safety issue and other events that impact patient safety within the hospital and available organizational resources to support the plan.

Analysis of the Root Cause

ADEs are unwanted, unexpected, or unintended outcomes after medication administration. ADEs result from an error occurring during the medication administration process. ADEs greatly compromise the safety of the patient and care quality and increase the risks of morbidity and mortality with significant financial implications (Bankes et al., 2020). ADEs can also significantly impact the patient’s quality of life and their experiences during the period of provision of care. The impact of ADEs varies from those that are intercepted before they occur to those that are life-threatening and cause a loss of life. The following is an incident for which the root cause analysis is being conducted.

Mrs. Sara is a 54-year-old Type 2 diabetic patient who had been admitted to the facility for the last three weeks but was discharged a week ago. She had been using glibenclamide during her hospital stay to manage her blood sugar, which had gone too high to life-threatening levels. She could not exercise regularly and noted that she could not manage to follow the diet plan that had been developed for her. Three days before her discharge, the physician noted that she had a case of hypoglycemia and changed her prescription to gliclazide. The new gliclazide regimen helped manage her blood sugar and reduced the risk of hypoglycemia. The physician confirmed that she continues taking gliclazide as she could not exercise and maintain the expected diet. A week after her discharge, she was brought to the hospital emergency care department with a case of severe hypoglycemia, general body weakness, nausea, and tremors, and she recorded two seizures in the last two days. The severe hypoglycemia and the accompanying symptoms were concluded as adverse drug events in relation to the medication she was taking.

After she was stabilized, a quick meeting involving the nurses and physicians on duty during the discharge of Mrs. Sara was called to help determine the causes of her severe hypoglycemia and the other symptoms she manifested. A root cause analysis (RCA) was ordered to investigate the causes of her condition and help develop interventions to support her care and reduce the risk of hypokinemia from becoming life-threatening.

The RCA identified a number of factors that had contributed to the ADE affecting Mrs. Sara. Firstly, the RCA found that, although the physician had prescribed gliclazide as a replacement for the glibenclamide, the patient still took both medications at once. This mistake was linked to the failure of the physician to indicate that the patient was no longer supposed to use glibenclamide. This miscommunication between the physician, the nurses, and the discharging team led to the patient getting glibenclamide and gliclazide. Further, there was no review of the discharge sheet during the release of the patient by either the discharge officer or the pharmacist during the dispensation of both medicines. Additionally, it was established that Mrs. Sara had used glibenclamide for a prolonged period, even before she was admitted to the facility. Glibenclamide has been found to have excellent glycemic control properties; however, it risks the development of severe hypoglycemia under prolonged use (Huang et al., 2019). Therefore, the RCA results can be interpreted to show the root causes, including poor interdisciplinary team communication, prolonged use of glibenclamide, and some aspects of negligence.

Application of Evidence-Based Strategies

The ADE affecting Mrs. Sara can be addressed through the application of evidence-based and best-practice strategies. The first aspect is to address safety by improving the safety of the process of drug treatment. Improving the medication treatment process means improving the competency of nurses and other healthcare professionals in the processes related to medication prescription and administration. The medication treatment process can be improved by standardizing all procedures for medication administration and pushing for double-checking before administering medications.

The RCA identified miscommunication during the prescription and ordering of the medications for the patient. Notably, evidence shows that miscommunication is responsible for a third of all ADEs that occur across all care settings (Ak, 2019). Such medication errors risking the occurrence of ADEs can be addressed through the adoption of technology-based information-managed systems within the facility. Live electronic health information management systems such as electronic health records (EHRs) have been shown to provide a patient’s history and health information in real time (Ak, 2019). EHRs have the potential to flag mistakes in prescription or administration, therefore adopting proactive monitoring and flagging of errors (Ak, 2019). Additionally, using advanced technologies such as machine learning enables the ability to analyze patient data stored in EHRs to identify any medication and safety risks (Guan, 2023).

The other root cause of the ADEs was the prolonged use of glibenclamide through Mrs. Sara’s treatment. Evidence shows that the continued use of medication is a critical factor that risks the occurrence of adverse events (Weir et al., 2020). This further shows a failure in the hospital transition of care teams. Therefore, it can be resolved by establishing a competent transition of the care team with case managers to educate the patients and their caregivers on caring for the patient and do follow-ups after discharge.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Improvement of care services and patient management is required across the entire facility. The proposed improvement plan adopts evidence-based strategies to improve patient safety by reducing the occurrence of medication administration errors and, hence, the occurrence of severe ADEs. The plan will focus on healthcare professionals and continuing medical education. The education and training will focus on educating the participants on interdisciplinary team communication, the use of EHRs and other electronic data collection and entry systems, and best practices during patient discharge and transition of care. Educational interventions in nursing have been linked to the improved ability of nurses to recognize and eliminate errors during the medication process (Tecklenborg et al., 2020). The plan’s goals include improving interprofessional communication, efficient use of EHRs to reduce medication errors, access and share patient information, and improved efficiency during the transition of care. The improvement plan will be developed within four weeks and will be implemented within the course of three months.

Existing Organizational Resources

The hospital is well-equipped with most of the resources required to support the development and implementation of the proposed evidence-based improvement plan. The hospital has a premium EHR system, wristbands with barcode identifiers, scanning systems, and other communication support systems. The plan will, therefore,, require funding to support staff training on how to optimally use these systems. Additionally, the existing resources will reduce the costs of implementing the plan.

Conclusion

ADEs are preventable events related to medication administration errors with significant impacts on patient safety. The existence of various causal factors requires the use of an RCA to establish the root causes of ADEs and develop issue-specific intervention and improvement plans. As observed in the case of Mrs. Sara, ADEs can be addressed by resolving their root causes and using evidence-based practices in managing such incidents.

References

Ak, M. (2019). International Patient History & Medical Record: Proper Solution from Accurate Problem Identification. Journal of Current Science and Multidisciplinary Research, 2(07), 115–120. https://doi.org/10.1007/s11096-018-0737-2

Bankes, D. L., Jin, H., Finnel, S., Michaud, V., Knowlton, C. H., Turgeon, J., & Stein, A. (2020). Association of a Novel Medication Risk Score with Adverse Drug Events and Other Pertinent Outcomes Among Participants of the Programs of All-Inclusive Care for the Elderly. Pharmacy 2020, Vol. 8, Page 87, 8(2), 87. https://doi.org/10.3390/PHARMACY8020087

Guan, M. (2023). Machine Learning for Analyzing Drug Safety in Electronic Health Records. In H. Hong (Ed.), Machine Learning and Deep Learning in Computational Toxicology. Computational Methods in Engineering & the Sciences. (pp. 595–610). Springer, Cham. https://doi.org/10.1007/978-3-031-20730-3_26

Huang, K., Hu, Y., Wu, Y., Ji, Z., Wang, S., Lin, Z., Xu, J., & Pan, S. (2019). Exploratory analysis of oral glibenclamide in acute ischemic stroke. Acta Neurologica Scandinavica, 140(3), 212–218. https://doi.org/10.1111/ANE.13134

Tecklenborg, S., Byrne, C., Cahir, C., Brown, L., & Bennett, K. (2020). Interventions to Reduce Adverse Drug Event-Related Outcomes in Older Adults: A Systematic Review and Meta-analysis. Drugs and Aging, 37(2), 91–98. https://doi.org/10.1007/S40266-019-00738-W/METRICS

Weir, D. L., Lee, T. C., McDonald, E. G., Motulsky, A., Abrahamowicz, M., Morgan, S., Buckeridge, D., & Tamblyn, R. (2020). Both New and Chronic Potentially Inappropriate Medications Continued at Hospital Discharge Are Associated With Increased Risk of Adverse Events. Journal of the American Geriatrics Society, 68(6), 1184–1192. https://doi.org/10.1111/

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Root-Cause Analysis and Safety Improvement Plan

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 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.

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 the 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 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, 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.
SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.

VIEW SCORING GUIDE