Root-Cause Analysis and Safety Improvement Plan
Abstract
<h2>Cover Page</h2> <p>Root-Cause Analysis and Safety Improvement Plan</p> <p>Student</p> <p>School of Nursing and Health Sciences</p> <p>NURS4020: Improving Quality of Care and Patient Safety</p> <p>Instructor</p> <p>Month, Year</p> <h2>Medication Errors and the Importance of Root-Cause Analysis</h2> <p>Medication errors are common and sometimes result in death. Medical errors can be defined as deliberate actions, such as using the wrong plan to achieve a goal, or departing from the recommended course of care in a way that could endanger the patient (Mutair et al., 2021). Caregivers and healthcare leaders must conduct a root-cause analysis to reduce medication errors. A detailed examination of an event and its contributing factors is known as a root-cause analysis (RCA). RCA is a popular investigation technique in the healthcare industry. It identifies systemic flaws that led to clinical incidents and determines how the associated risks can be controlled or eliminated (Kwok et al., 2020). Medication errors occur for various reasons, and identifying their underlying causes can help reduce the likelihood of recurrence. Lowering the frequency of medication errors is an important strategy for improving patient safety. This report examines a safety improvement plan and the underlying causes of medication errors in nursing homes.</p> <h2>Human and Systemic Causes of the Sentinel Medication Event</h2> <p>Unfavorable incidents within the healthcare system cause harm to patients, organizations, and participating providers (Brabcová et al., 2023). In one case study, a nurse administered the incorrect medication to a nursing home patient. When the patient began experiencing convulsions, another nurse at the facility noticed that the patient was exhibiting adverse symptoms of poisoning. The patient later died, and the nursing home and nurse were sued for patient negligence. Because the incident resulted in the patient’s death and adversely affected the nurse and healthcare organization, it was classified as a sentinel event. Several factors contributed to the event, including systemic and human issues.</p> <p>In the case described above, systemic and human issues contributed to the medication error. Human errors may result from a person’s carelessness or a practitioner’s cognitive dysfunction. The nurse’s pharmaceutical knowledge was at the root of the problem because the nurse could not correctly identify the medication administered to the patient (Brabcová et al., 2023). The primary human factor contributing to the nurse’s inability to identify the medication correctly was the absence of the necessary tools to assess the medication label and confirm the patient’s identity. The nurse’s involvement in the medication error resulted from cognitive failure.</p> <p>In addition, systemic factors indirectly contributed to the error. A common issue affecting the healthcare industry is a shortage of nurses, which places considerable strain on nursing home staff. A high workload was one systemic factor that contributed to the medication error because it caused burnout and reduced the nurse’s attention to detail.</p> <h2>Evidence-Based Medication Error Prevention Strategies</h2> <p>Evidence-based interventions could have prevented the reported medication error. As previously mentioned, the nurse’s inability to determine accurately the medication and the patient to whom it should be administered was primarily responsible for the error. Consequently, increasing nurses’ pharmacological knowledge is essential (Brabcová et al., 2023). Studies indicate that educating nurses about the five rights of medication administration can help reduce medication errors. Nurses should therefore receive training on selecting the right patient, medication, dose, time, and route of administration.</p> <p>Using technology to reduce the margin of error among nurses is another evidence-based strategy. Nursing homes may employ various technologies to improve medication safety. Medication error rates have been shown to decrease when computerized physician order entry (CPOE) and barcode medication administration (BCMA) are combined (Gauthier-Wetzel, 2020). These technologies improve care coordination and reduce the likelihood of errors during medication administration. They also help nurses identify patients and medications, lowering the possibility that the wrong patient or medication will be selected.</p> <p>The final strategy is to make medication reconciliation a routine procedure so that healthcare professionals remain fully informed about the patient’s prescriptions and medical condition. Medication reconciliation can help identify omissions, duplications, incorrect doses, and potentially harmful drug interactions before medication is administered.</p> <h2>Evidence-Based Safety Improvement Plan for Nursing Homes</h2> <p>It is recommended that nursing homes use best practices and evidence-based measures to implement an improvement plan and minimize medication errors. The nursing home facility should take several actions. First, it should implement BCMA to identify patients and medications more accurately. BCMA uses barcodes to verify the identity of patients through their identification tags and to confirm medications through corresponding codes (Gauthier-Wetzel, 2020).</p> <p>The nursing home facility should incorporate this technology and use barcode-equipped identification tags to improve patient and medication recognition while reducing the likelihood of medication errors. To improve care coordination and lower the risk of medication errors, BCMA can be used alongside the existing CPOE system. The facility should provide nurses with handheld barcode scanners for patient and medication identification, thereby minimizing the possibility of mistaken identities.</p> <p>Developing a sterile cockpit rule and providing nurse education are additional strategies for decreasing medication errors in nursing homes. The sterile cockpit rule would establish a designated area in which medication preparation occurs without avoidable interruptions or unrelated conversations. Nurse education should address pharmacological knowledge, medication identification, the five rights of medication administration, and the correct use of BCMA equipment.</p> <h2>Organizational Resources Required for Implementation</h2> <p>The new technology and medication administration procedures will make the improvement plan resource-intensive. Electronic health records (EHRs) are already maintained in the facility’s database. These records make it easier to track the medications taken by each patient (Bates & Zebrowski, 2022). This resource will be essential for BCMA implementation because it will support medication data storage and collection.</p> <p>Nevertheless, the organization must purchase BCMA equipment and train nurses to use it during medication administration. Required equipment may include handheld barcode scanners, barcode-compatible medication labels, and patient identification bands. Training will also be necessary to ensure that nurses can respond appropriately when the system identifies a discrepancy.</p> <p>The medical facility also has an unoccupied space that can be used to store medications and apply the sterile cockpit rule. The lead nurse should designate and mark the area clearly and instruct other nurses on how it should be used. Limiting interruptions within this space can improve concentration and reduce medication preparation errors.</p> <h2>Integrated Patient Safety and Quality Improvement Outcomes</h2> <p>Reducing medication errors is one way to improve patient safety, which is a critical objective in nursing homes. By teaching nurses safe medication administration practices and implementing BCMA, the facility can lower the possibility of future medication errors. The new procedure will improve safety by reducing interruptions during medication preparation and increasing the accuracy of patient and medication identification.</p> <p>Medication errors such as the one discussed in this report harm patients and negatively affect healthcare systems and the professionals involved. The root-cause analysis demonstrates that the incident resulted from both human and systemic factors. Therefore, an improvement plan involving nurse education, BCMA, CPOE, medication reconciliation, and sterile cockpit procedures must be implemented to reduce the likelihood of similar errors in the future.</p> <h2>References</h2> <p>Bates, D. W., & Zebrowski, J. (2022). Medication safety in nursing home patients. BMJ Quality & Safety, 31(12), 849-852.</p> <p>Brabcová, I., Hajduchová, H., Tóthová, V., Chloubová, I., Červený, M., Prokešová, R., ... & O’Hara, S. (2023). Reasons for medication administration errors, barriers to reporting them and the number of reported medication administration errors from the perspective of nurses: A cross-sectional survey. Nurse Education in Practice, 70, 103642.</p> <p>Gauthier-Wetzel, H. E. (2020). Barcode medication administration in the emergency department to mitigate medication errors (Doctoral dissertation, Walden University).</p> <p>Kwok, Y. T. A., Mah, A. P., & Pang, K. M. (2020). Our first review: An evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals. BMC health services research, 20(1), 507. https://doi.org/10.1186/s12913-020-05356-6</p> <p>Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., ... & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46.</p>