Root-Cause Analysis and Safety Improvement Plan for Medication Administration

Root-Cause Analysis and Safety Improvement Plan for Medication Administration

According to Schramme (2016), the central goal of medication is to achieve desired therapeutic outcomes that improve the patient’s wellness and quality of life. Health professionals also seek to provide medication and care therapies that achieve such therapeutic objectives with minimum harm to the patient (Rodziewicz et al., 2018). However, known or unknown errors are inherent in the treatment process, with risks associated with such errors during medications. Medication errors are the most commonly reported medical errors during the treatment process of patients in the facility. The majority of the reported medication errors occur during the administration phase. Such medication administration errors threaten patient safety within the care settings. Therefore, there is a need to understand the root causes of errors during medication administration and develop an evidence-based initiative to improve the safety of medication administration and prevent errors from recurring.

This paper presents a root cause analysis for medication administration in an in-patient care facility. The causes of such errors and the elements essential for improving medication administration safety are identified. The article also develops an evidence-based safety improvement plan for safe medication administration. The paper also analyzes the existing organizational resources and interventions that support a successful evidence-based strategy for improving safe medication administration. Hire our assignment writing services in case your assignment is devastating you. We offer assignment help with high professionalism.

Root-Cause Analysis and Safety Improvement Plan for Medication Administration

According to Wondmieneh et al. (2020), unsafe medication administration errors are the leading causes of preventable adverse health outcomes in patients, such as disability and death. They also affect health professionals and health organizations and can lead to forfeiture of practice licensing and criminal liability. Reducing and preventing medication errors is complicated, but it is necessary to improve patient safety (Tariq et al., 2021). It is important to carry out a root-cause analysis (RCA) to identify the causes of errors and elements essential to prevent such errors, improve patient safety, and reduce errors associated with medication administration. An RCA in healthcare is a problem-solving technique that aims to identify and understand the root causes of errors and other issues and how to fix them (Martin-Delgado et al., 2020).

The nurse manager identified 18 incidents of reported MAEs in the inpatient facility in the last six months. Considering the threat of medication administration errors on patient safety and the overall consequences of such errors to the clinicians and the facility, an RCA was conducted on the reported errors to identify their root causes. It was identified that all cases were reported by nurses who had administered medication to in-hospital patients. Ninety-two percent of the cases were directly caused by errors from the nurses’ side, while eight percent of the cases resulted from patient faults.

The RCA on causes of medication administration errors noted that 42 percent of the errors resulted from a lack of knowledge of drug information, including drug-to-drug interactions and drug action. In addition, 26 percent resulted from a lack of adequate communication with physicians, while 17 percent resulted from wrong medication calculations leading to wrong dosages. Eight percent of the reported cases were due to administering medications to the wrong patient. Three percent were linked to distraction and stress during the administration. Two percent were due to the patients moving during intravenous administration, leading to the errors, while 2 percent were due to administering the right medication using the wrong route.

Only eight percent of the reported errors resulted in patient harm while 92 percent did not cause any adverse drug outcomes; however, they have the capacity to compromise patient safety within the facility. Due to the clinical equation of errors to duty failure, the fear of associated punishment and legal action, and other associated consequences, a clinician may be reluctant to report errors (Rodziewicz et al., 2018). This means that the reported medication administration errors do not represent the actual number of errors occurring within the inpatient facility. The uncertainty of errors occurring getting reported creates a need to develop targeted, evidence-based initiatives to improve the safety and quality of medication processes and prevent medication administration errors.

According to the RCA, a majority of errors result from a lack of knowledge of drug information, including drug-to-drug interactions and drug action. The lack of adequate communication with physicians was also noted as a major cause for concern in medication administration safety. The RCA noted that nurses are central in the occurrence and prevention of medication administration errors.

Application of Evidence-Based Strategies to Reduce and Prevent Medication Administration Errors

Wondmieneh et al. (2020) concluded that nurses were more likely to cause medication errors due to failure to follow guidelines, work experience, interruptions from patients, and other environmental factors. Escrivá Gracia et al. (2019) linked the drug-knowledge gap to such errors, while Tariq et al. (2021) related MAEs to incorrect dosage, dose preparation, timing, and lack of information on interactions and contraindications.

Research on medication safety has identified various evidence-based strategies to prevent MAEs. Improving drug knowledge among transcribers and using assistive technology during drug administration have been identified as major evidence-based strategies for preventing medication administration errors. The improvement of communication has also been noted to improve the quality of medication administration. Wondmieneh et al. (2020) suggested training nurses and providing clear guidelines to nurses. Rozenblum et al. (2020) identified that the use of machine learning systems in medication administration could help identify and prevent medication errors and impact patient safety.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The RCA identified the major cause of mediation administration errors in in-patient care as majorly related to nurses due to lack of sufficient pharmacological knowledge and communication between the nurses and physicians. The improvement plan for medication administration will focus on training and improving the nurses’ pharmacological knowledge and improving nurse-doctor communication.

The knowledge of medication information, including drug-drug interaction, contraindications, and other pharmacological information among the nurses, is critical in the safe administration of medication (Tariq et al., 2021). Training is a major strategy for improving nurses’ knowledge of medication information (Rodziewicz et al., 2021). The medication administration improvement plan will carry out refresher courses for all nurses within the facility with the physician’s and the pharmacy department’s support and include external training and development sessions. Effective nurse-physician communication and collaboration are important to achieving quality patient care. To improve communication among the basic caregivers, the improvement plan will consider evidence-based strategies for better communication suggested by Wang et al. (2018). The improvement plan will adopt the use of communication tools/checklists, nurse-physician team training, multidisciplinary structured work shift evaluation, and technology-based communication systems.

Existing Organizational Resources

The success of the medication administration improvement plan depends on the available organizational resources and the willingness of the nurses and physicians to get engaged in the improvement process. Using the existing resources within the facility will reduce the costs and time spent on the nurse and physician training and implementation of the other elements of the improvement plan, including technologies to support data recording for improved medication administration and quality of patient care.

The facility already has an existing quality-approved electronic health records (EHR) system. There are also monitoring systems in all in-patient facilities that can be linked with the central EHRs and communication systems to provide support to the nurses during medication administration. The employees, such as the pharmacists and other physicians, are willing to engage and train with the nurses to improve medication administration safety. An external trainer can also be organized to come to the facility, and training can be conducted within the facility as it has meeting rooms that can be equipped to provide a learning environment.

Conclusion

Medication administration errors compromise the quality and safety of healthcare. Reducing and preventing medication administration errors includes the identification of the active causes and developing evidence-based strategies to resolve and manage such cases. Some minor errors may go unreported and unresolved. However, this does not eliminate their occurrence. Major administration events may trigger such minor errors, leading to catastrophic outcomes. Therefore, an RCA is critical on the reported errors to identify the underlying causes for both reported and unreported medication errors. Nurse training is an evidence-based strategy that improves medication knowledge and communication among clinicians. Improving the safety of medication administration improves the quality of care with improved patient outcomes, achievement of care objectives, and positive professional and business outcomes for both the clinicians and the health organization.

References

Escrivá Gracia, J., Brage Serrano, R., & Fernández Garrido, J. (2019). Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC health services research, 19(1), 1-9.

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis translates into improved patient safety: A systematic review. Medical Principles and Practice, 29(6), 524-531.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2018). Medical error prevention.

Rozenblum, R., Rodriguez-Monguio, R., Volk, L. A., Forsythe, K. J., Myers, S., McGurrin, M., … & Seoane-Vazquez, E. (2020). Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation. The Joint Commission Journal on Quality and Patient Safety, 46(1), 3-10.

Schramme, T., 2016. Goals of Medicine. Handbook of the Philosophy of Medicine, pp.1-8.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication Dispensing Errors And Prevention [Updated 2021 May 12]. StatPearls [Internet]; Treasure Island (FL): StatPearls Publishing.

Wang, Y. Y., Wan, Q. Q., Lin, F., Zhou, W. J., & Shang, S. M. (2018). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. International journal of nursing sciences, 5(1), 81-88.

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1), 1-9.

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Hello i attached the rubric. I will also attach the root cause analysis guide

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.

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 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.