Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

A root cause is defined as a factor that makes an individual fail to conform to procedures as dictated. This necessitates the need to eliminate this factor completely through improvement. Root causes are usually the reason why the cause-and-effect reaction takes place with the potential to lead to the problem(s). Root cause analysis can be defined as a term that describes the approaches, tools, and techniques that are applied with the aim of uncovering the causes of a specific problem. This paper looks at a root-cause analysis of medication errors within the hospital setting, with the main focus being on the description and analysis of these medication errors.

Root-Cause Analysis of Medication Errors

A medication can be defined as a substance that is used in the treatment, prevention, or alleviation of the symptoms of a disease. An error can defined as the act of carrying out an activity using an incorrect procedure. Errors usually occur as a result of failing to complete an action as required, making a mistake, or ignorance. A medication error can, therefore, be defined as the failure of an individual to administer medication following the required procedure, which has the potential to lead to harm (World Health Organization, 2016).

There are various reasons why medication errors occur. This can be through inappropriate or irrational choice of medications, ineffective prescribing, under-prescribing, and overprescribing. Medication errors are also likely to occur when writing down the prescription (illegibility). They can occur during the manufacture of the formulation to be used. They can occur during the distribution of the formulation where the wrong drug, formulation, or label is distributed. It is also possible for medication errors to occur during the monitoring of the therapy where the therapy is altered erroneously or alteration is not done at all (Okes, 2019).

It is not clearly known how frequently medication errors occur. This is so because detection methods are likely to affect the estimated frequency of medication errors. This means that there are many medication errors which are never noticed. Among the detected medication errors, just a few of them may lead to adverse drug reactions or have the potential to lead to other serious effects. No matter how serious a medication error is, detecting it is important since it helps uncover a failure in the treatment process so as to prevent harm on another occasion (Naples et al., 2016). There are a number of reasons that support the trend of the increase in the number of deaths as a result of medication errors. Today, there has been an increase in the number of emerging drugs that are difficult to use safely and effectively. Today, medical care is becoming more and more specialized and complex. The aging of the population with complex medical needs has also led to an increase in the occurrence of medication errors. Also, medication errors have been on the rise as a result of the fact that hospitals have been seeing an increase in the throughput of patients.

The causation of medication errors is brought about by a number of factors. In many cases, medication errors committed by nurses occur due to fatigue among nurses, low nurse-patient ratio, dealing with many critically ill patients at the same time, and receiving unreadable and damaged orders from doctors (World Health Organization, 2016).

Application of Evidence-Based Strategies to Address Medication Errors

The occurrence and avoidance of medication errors can be understood best through classification. Medication errors can be classified into a number of categories that may include contextual (place, medicines, time, and people involved), modal (ways through which medication errors occur), and psychological (explaining events). Psychological classification is mostly preferred over the other two categories.

Several evidence-based strategies can be used to address medication errors. Adherence to the five rights of medication administration and following proper medication reconciliation procedures is of great significance. Healthcare providers should double-check procedures before performing them. This helps to ensure that the orders for each patient are noted and that the same are transcribed correctly on the physician’s order, as well as the medication administration record. Nurses should read back orders to the prescribing physicians. It is also important for healthcare providers to use name alerts, especially for cases where patient names sound similar, to avoid the mix-up of medications. Nurses should also use drug guides at all times, ensure proper storage of medications for proper efficacy, and ensure that everything is documented correctly. It is also important for healthcare providers to have knowledge about their organization’s medication administration guidelines, regulations, and policies (Tariq, Vashisht & Scherbak, 2020).

Improvement Plan and Existing Organizational Resources

Healthcare providers should have comprehensive knowledge of the strategies used in the prevention or reduction of medication errors. Various strategies are available for this purpose. As mentioned above, it is important for healthcare providers to ensure that they adhere to the five rights of medication administration and follow proper medication reconciliation procedures. Healthcare providers should double-check procedures before performing them. This helps ensure that the orders for each patient are noted and that the same are transcribed correctly on the physician’s order as well as the medication administration record (World Health Organization, 2016). Nurses should read back orders to the prescribing physicians. It is also important for healthcare providers to use name alerts, especially for cases where patient names sound similar, to avoid the mix-up of medications. Nurses should also use drug guides at all times, ensure proper storage of medications for proper efficacy, and ensure that everything is documented correctly. It is also important for healthcare providers to have knowledge about their organization’s medication administration guidelines, regulations, and policies (World Health Organization, 2016).

Several organizational resources can be leveraged so as to bring about improvement in relation to medication errors. Some of them include ensuring interoperability of the electronic health records adopted by the organization, ensuring that pharmacists are involved in direct patient care, and using handoff conversations properly. Appropriate utilization of electronic health records has the potential to lead to a significant reduction in medication errors.

Conclusion

In conclusion, a root cause is defined as a factor that makes an individual fail to conform to procedures as dictated, which necessitates the need to eliminate it completely through improvement. A medication error can be defined as the failure of an individual to administer medication following the required procedure, which has the potential to harm the patient. There are various reasons why medication errors occur. No matter how serious a medication error is, detecting it is important since it helps uncover a failure in the treatment process so as to prevent harm on another occasion. Several evidence-based strategies can be used to address medication errors. Adherence to these strategies can be effective in the prevention or reduction of medication errors.

References

Naples, J. G., Hanlon, J. T., Schmader, K. E., & Semla, T. P. (2016). Recent literature on medication errors and adverse drug events in older adults. Journal of the American Geriatrics Society, 64(2), 401-408.

Okes, D. (2019). Root cause analysis: The core of problem-solving and corrective action. Quality Press.

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet]. World Health Organization. (2016). Medication errors. World Health Organization.