NURSFPX4020 Capella University Safety Improvement Plan Analysis PaperMedication Errors Root Cause An

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

Medication Errors Root Cause Analysis and Safety Improvement Plan Example Approach

Root cause analysis (RCA) is a tool used to investigate and understand the underlying causes of patient safety incidents, such as medication errors (Ahmed et al., 2019). It helps in problem identification so that health practitioners can introduce changes that improve care quality and patient experience. Medication errors are a typical incident that requires an RCA that will ultimately produce various recommendations to reduce medication errors and improve patient safety.

The application of RCA to medication errors within a clinical care setting is critical considering the alarming numbers of increased length of stay, hospital injuries and death that adverse events have caused in American hospitals (Gates et al., 2019). For instance, according to Mazer and Nabhan (2019), at least 200,000 deaths are attributable to medication errors yearly, indicating that various root cause factors play a role in those events and are worth exploring. This report covers an RCA of ten hospitals in the US, analyzing and describing the fundamental causes and major contributors to medication errors, as well as an evidence-based plan and resources for improving patient safety.  

Root Causes Of Medication Errors And Evidence-Based Solutions

When nurses, pharmacists, or physicians offer any type of healthcare service to patients, they can unknowingly inflict injury on the patient or cause adverse events such as medication errors or misdiagnosis. As per Gates et al. (2019), 10-20% of medication orders contain medication errors depending on the adverse event, for instance, delayed medicine administration.

However, Gates et al. (2019) also found out that serious medication errors make up 5% of medication administrations in the US.  In the case of Delaware Community Clinic, the management reports collected over the past 30 days indicated that for every 100 medication administration cases, seven errors are experienced. This number is above the acceptable rate of medication errors.

The data was collected through direct and non-participant medication preparation and delivery observations. The non-participatory observation of medication errors yielded important information about medication errors. For example, it was observed that distractions and secondary events were among the direct causes of medication errors in the Delaware Community Clinic.

While most medication errors are preventable, they cause an array of adverse events, such as triggering new health conditions, patient injury, or, in the worst cases, death (Ibrahim et al., 2020). Medication errors also lengthen hospital stay, increases the cost of healthcare, and inflicts psychological or physical pain on the patient and their families. Medication errors in healthcare organizations reduce patient satisfaction and ultimately contribute to trust issues among nurses, physicians, and entire health organizations.

The RCA was conducted by a team of six practitioners, including a clinician, a supervisor, two quality improvement personnel and two nurses. The medication errors were recorded through nurse observations, emphasizing medication ordering and administration services. The error cases were categorized under prescription omission, wrong timing, improper usage, dose preparation and dosage, medication administration errors including extra dosage, and giving the wrong patient.

The observed incidences revealed that time, unauthorized administration, and dosage errors were the most prevalent, accounting for 17, 10 and 18 percent of the medication errors, respectively. The observations also indicated that the errors occur during periods of high activity, for instance, during shift changes and emergency calls. The RCA also showed that staff-related causes of medication errors were attributable to inadequate pharmacological knowledge.

For instance, it was observed that nurses who lacked the ideal knowledge of the ideal medication administration route were likely to cause incidences of intravenous injections. The errors were also observed to be highly associated with poor knowledge of drug pharmacological properties as well as excessive dosage. These errors were observed to be primarily caused by the complex nature of intravenous medication, which requires vast experience to deliver the drug as optimally as possible.

Notably, the nurses who made these mistakes showed a lack of in-service training among newer staff, which constrained them of the necessary knowledge to prepare and deliver the drugs. As Mazer and Nablan (2019) recommended, in-service training on pharmacology and administration of complex medicine could be an excellent approach to reducing such medication errors.

The second root cause of medication errors in the Delaware Community Clinic was a shortage of nurses, which increased the workload of nurses needed at one point in time. Interviewed nurses revealed that medication errors were highly attributable to understaffing because nurses were pressured to cover the workload. Therefore, some evidence-based solution to understaffing is employing more nurses, ensuring a smoother change of shifts, and supporting the nursing staff as much as possible (Mazer & Nabhan, 2019). For instance, during the root cause analysis, it was observed that some laboratory staff could call the physicians to collect the lab results physically.

However, the results could easily be transmitted to the physician using an electronic medical records system (EMRs). Rezaei (2019) recommends that EMRs can reduce medication errors by facilitating fast, efficient, and reliable transmission of patient information between nurses, pharmacists, laboratory technicians and the patient. Using technology to transmit necessary information, such as lab reports, could help minimize the pressure that comes with physically handling the data.

Improvement Plan

The improvement plan following this RCA will take two approaches: improving staff’s skills and knowledge and making the necessary environmental changes to minimize medication errors. The first item of the plan is to improve the hospital’s medication monitoring system to improve staff coordination and enhance prescription accuracy through various cross-checking points and communication among staff. The second improvement plan will be to train the staff to prevent medication errors, especially when administering complex medications such as intravenous injections. The training should improve the nurses’ pharmacological knowledge, especially on new drugs, contraindications, dosages, and proper administration.

Conclusion

Medication errors are associated with lengthened hospital stays, injury, increased care costs and even death. An RCA of the factors contributing to medication errors revealed important information on some of the leading causes and their potential solutions. The report indicated that nurses’ lack of skills and knowledge, followed by poor communication and distractions, are the most common cause of medication errors. Some of the evidence-based strategies for addressing the problem include the improvement of staff skills and knowledge and making the necessary environmental changes to minimize medication errors. These two solutions will provide a ground approach to minimizing medication errors in Delaware Community Hospital.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper References

Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14. https://doi.org/10.1371/journal.pone.0217023

Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardizing the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931–939. https://doi.org/10.1007/s40264-019-00823-4

Ibrahim, O.M., Ibrahim, R.M., Meslamani, A.Z.A., & Mazrouei, N.A. (2020). Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes. Pharmacy Practice (Granada), 18(4), 2111. https://doi.org/10.18549/PharmPract.2020.4.2111

Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267. https://doi.org/10.1007/s11606-019-05156-7

NURSFPX4020 Capella University Root-Cause Analysis and Safety Improvement Plan Example 2

A root-cause analysis is a method of problem-solving that entails determining the primary reason for a situation or issue to stop it from happening again in the future. Investigating the root causes of safety problems and potential remedies is often part of a safety improvement plan.

Organizations wishing to increase safety and prevent accidents or incidents must apply root-cause analysis and safety improvement planning. Organizations may make their workplaces safer and more productive for both their employees and clients by recognizing and addressing the fundamental causes of issues. This paper aims to conduct a root cause analysis of an incident that risked patient safety in my health organization and develop a safety improvement plan from the analysis.

Analysis of the Root Cause

Mr. X, a 52-year-old black male, had been hospitalized for three days for treatment but was diagnosed with stage II hypertension during his inpatient stay. As part of his treatment plan, he was prescribed Lisinopril tablets, a medication used to lower blood pressure, to be taken once daily at a dosage of 10mg upon his discharge from the hospital. The medication was dispensed by a licensed pharmacist, who checked that it was the correct medication and had not expired. However, the pharmacist made a mistake and provided the patient with 20mg tablets of Lisinopril instead of the prescribed 10mg tablets.

The patient, who was also a healthcare professional, took the medication as directed and subsequently experienced severely low blood pressure and dizziness, requiring emergency care the next morning. This error occurred despite the pharmacist’s efforts to ensure the accuracy and safety of the medication. The patient received treatment at the emergency department and recovered from the adverse reaction to the medication. This incident highlights the importance of careful medication management in preventing adverse events and the need for proper training and oversight of healthcare professionals.

The nurses discovered this problem at the emergency department who, during medication reconciliation and health history building, questioned the patient’s past medical and medication history. The nurse wanted to know the reason for this unplanned readmission within 48 hours after discharge. The patient, Mr. X, was impacted by the issue or event in the scenario mentioned above. Mr. X’s extremely low blood pressure and disorientation were caused by the pharmacist’s mistake in the medication he dispensed, necessitating emergency care. As a result, Mr. X had a great deal of stress and inconvenience, and it is possible that this had a detrimental effect on his physical and mental well-being.

The error might have potentially resulted in long-term effects if it had not been caught right afterward. Patients who experience medication errors may experience adverse side effects, damage, or even death (Assiri et al., 2018). Healthcare providers must adhere to established protocols and procedures to ensure patient safety and minimize avoidable mistakes. Healthcare providers must adhere to established protocols and procedures to guarantee patient safety and minimize avoidable mistakes. Patients should be knowledgeable about their prescriptions and speak out if they have any concerns or inquiries.

Root Cause Analysis

As part of his hypertension treatment plan, Mr. X was given a prescription for Lisinopril pills at a dosage of 10mg once daily and was meant to be discharged from the hospital. A qualified pharmacist was required to dispense the drug and ensure that it was the right one and that it had not expired. However, the pharmacist misread the prescription and gave Mr. X 20mg of Lisinopril tablets rather than the 10mg tablets that were intended.

Despite the pharmacist’s best efforts to ensure the medication’s accuracy and safety, this error nonetheless happened. The usual chain of medication use in the facility is that upon the prescription of medication by the physician or an advanced practice registered nurse, the nurse should check the prescription and obtain the correct medication from the pharmacists.

In case of uncertainty, the nurse, as the professional administering the medication, should check with the prescriber to ascertain that the prescription is safe and appropriate for the patient and that all the five R’s of medication use are considered in the prescription. The pharmacists should ensure that the patient gets the right medication with the correct dose per the prescription. In cases of uncertainty, the pharmacist should check with the prescriber and professional administering the medication to prevent errors. Another role of the nurse in this system is ensuring that the patient understands their prescription and is aware of adverse effects, when to seek emergency help, and when to expect clinical improvement.  

The environmental factors that played a part in this case can only be inferred from the documented evidence-based literature. In this scenario, the physical environment could have played a part in this issue because of the external distractions in the case of heavy workload in the inpatient pharmacy. Distractions from colleagues or other patients could have deterred the pharmacist from double-checking the dosage strength of Lisinopril dispensed.

The presence of a heavy workload from the high number of patient cases being handled could have played a role in this error. The inpatient pharmacy dispenses medication daily to more than five units in the hospital. Patients being discharged may be highly likely to be overlooked because of the presumed stable condition and thus might not require much attention as opposed to patients requiring emergency care and close monitoring.

The absence of automatic dispensing cabinets for patients being discharged could have influenced this medication error. Barcode medication administration (BCMA) systems could have also prevented this error by assisting the pharmacist in double-checking the prescription. BCMA and automatic dispensing cabinets can promote medication safety by ensuring that the prescription by the physician or the advanced practice registered nurse could be translated accurately to the dispensing department (Williams et al., 2021). Other technologies can also support or complement these technologies in ensuring medication safety.

The medication provided to the patient may have been incorrect due to several communication-related problems. A breakdown may have significantly influenced the circumstances leading up to this problem in communication between the prescribing doctor and the pharmacist over the appropriate dosage and frequency of the medicine.

This incident might have been caused by a communication breakdown between the pharmacist and the patient regarding the drug and how to use it properly. The strength of the medication may have been overlooked due to inadequate or unclear documentation or labeling of the drug, which could have caused confusion or misunderstanding.

Nevertheless, written or verbal communication, synchronous or asynchronous, played a critical part in this event. The presence of protocols for communication and guidelines for medication treatment was lacking in this patient’s case. These protocols can ensure accountability and empower teamwork when followed in a coordinated fashion (Russ-Jara et al., 2021). The need for collaboration, leadership, and management is thus evident from the literature.  

Application of Evidence-Based Strategies

To address the issue of medication errors, healthcare organizations can implement various best practice strategies. One strategy is to use electronic prescribing systems, which provide accurate and up-to-date medication information and can reduce the risk of errors by eliminating the need for handwritten prescriptions and facilitating communication between prescribing physicians and pharmacists (Mohanna et al., 2022).

Another strategy is to conduct medication reconciliation, which involves reviewing and comparing a patient’s current medications with those prescribed at previous healthcare encounters to ensure that the patient is receiving the correct medications and dosages. Providing ongoing education and training for staff on medication administration protocols, proper labeling and documentation, and error prevention strategies can also help prevent errors (Vaismoradi et al., 2020). 

Creating a culture of safety within the organization, where staff feel comfortable reporting errors and identifying potential risks, and implementing a medication error reporting system to identify patterns and trends can also contribute to preventing errors and ensuring patient safety (Mutair et al., 2021).

Our healthcare organization must regularly assess its medication management processes and identify potential areas for improvement to prevent errors (Afaya et al., 2021). According to Chui et al. (2019), addressing medication safety should be multidisciplinary and multifaceted because factors of medication errors cut across more than one discipline and profession. Therefore, these evidence-based strategies would require implementation in all stakeholder departments in our health organization.

Improvement Plan with Evidence-Based and Best-Practice Strategies

A proposed plan for this health organization will include implementing certain additional technologies, regularly training staff on medication safety, establishing an error-reporting system, and developing policies for medication safety. These strategies can help reduce the risk of errors by providing accurate and up-to-date medication information, facilitating better communication between prescribing physicians and pharmacists, reviewing and comparing a patient’s current medications with those prescribed at previous healthcare encounters, ensuring that staff has the necessary knowledge and skills to safely manage medications, establishing clear protocols for medication management, and identifying patterns and trends in medication errors to allow for targeted interventions (Mohanna et al., 2022). 

Specific additional technologies required will be Computerized Physician Order entry (CPOE), BCMA, and automated dispensing cabinets. Impending these technologies would require roughly half a year owing to the lengthy process of procurement, budgetary approval, training staff on their usage, and engaging all stakeholders to evaluate outcomes. However, other strategies, such as continuous staff education, establishing error reporting systems, and policy development, could be completed in a month after stakeholder consultations.

Existing Organizational Resources

Implementing the above plan would require human, technological, and financial resources. The organization already has healthcare professionals who can implement the plan. However, additional staff in the pharmacy and technology department would make this plan more feasible because it would reduce the workload on the existing human resources.     

Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan. The additional resources necessary would require an electronic health record (EHR) or a computerized method of managing patient information. The institution already has an EHR that can complement the BCMA, CPOE, and automated dispensing cabinets. Most importantly, financial resources would be critical in enhancing this improvement plan. Purchasing the additional technologies, implementing them, and compensating the involved personnel could require additional funds from the institution’s supplementary budget or outside sources.

Conclusion

Root-cause analysis is an essential method for identifying the primary causes of safety issues to prevent them from occurring again in the future. In this case, a root-cause analysis was conducted on an incident in a healthcare organization where a patient was given an incorrect medication dosage, leading to adverse effects requiring emergency care. The root cause of this incident was determined to be a mistake made by the pharmacist in reading the prescription and dispensing the wrong dosage of medication. 

A safety improvement plan was developed to address this issue and prevent similar incidents from occurring in the future. This plan includes strategies such as implementing an electronic prescribing system, conducting medication reconciliation, providing ongoing education and training for staff, developing clear policies and procedures for medication management, and implementing a medication error reporting system. By implementing these strategies, healthcare organizations can improve patient safety and minimize the risk of preventable medication errors.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper References

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21(1), 1156. https://doi.org/10.1186/s12913-021-07187-5

Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aljadhey, H., & Sheikh, A. (2018). What is the epidemiology of medication errors, error-related adverse events, and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open, 8(5), e019101. https://doi.org/10.1136/bmjopen-2017-019101

Chui, M. A., Pohjanoksa-Mäntylä, M., & Snyder, M. E. (2019). Improving medication safety in varied health systems. Research in Social & Administrative Pharmacy: RSAP, 15(7), 811–812. https://doi.org/10.1016/j.sapharm.2019.04.012

Mohanna, Z., Kusljic, S., & Jarden, R. (2022). Investigation of interventions to reduce nurses’ medication errors in adult intensive care units: A systematic review. Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses, 35(4), 466–479. https://doi.org/10.1016/j.aucc.2021.05.012

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046

Russ-Jara, A. L., Luckhurst, C. L., Dismore, R. A., Arthur, K. J., Ifeachor, A. P., Militello, L. G., Glassman, P. A., Zillich, A. J., & Weiner, M. (2021). Care coordination strategies and barriers during medication safety incidents: A qualitative, cognitive task analysis. Journal of General Internal Medicine, 36(8), 2212–2220. https://doi.org/10.1007/s11606-020-06386-w

Vaismoradi, M., Tella, S., A Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 2028. https://doi.org/10.3390/ijerph17062028

Williams, R., Aldakhil, R., Blandford, A., & Jani, Y. (2021). Interdisciplinary systematic review: Does alignment between system and design shape adoption and use of barcode medication administration technology? BMJ Open, 11(7), e044419. https://doi.org/10.1136/bmjopen-2020-044419

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper Resources:

Collaboration and Teamwork

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329–342.

• Consider applying some of the communications best practices highlighted in this article to how you communicate your tool kit.

Dietz, A. S., Pronovost, P. J., Mendez-Tellez, P., Wyskiel, R., Marsteller, J. A., Thompson, D. A., & Rosen, M. A. (2014). A systematic review of teamwork in the intensive care unit: What do we know about teamwork, team tasks, and improvement strategies? Journal of Critical Care, 29(6), 908–914.

• The authors discuss best practices related to teamwork and team improvement, some of which may help you think about how best to present the information in your tool kit.

Kalisch, B. J., Aebersold, M., McLaughlin, M., Tschannen, D., & Lane, S. (2015). An intervention to improve nursing teamwork using virtual simulation. Western Journal of Nursing Research, 37(2), 164–179.

• This article presents a feasibility study for use of a simulation to improve teamwork among nursing staff.

Malamed, C. (n.d.). Using wikis for learning and collaboration. ;Retrieved from http://theelearningcoach.com/elearning2-0/using-wi…

• This article may be helpful as you think about how to put together your tool kit for your assessment.

MindTools. (n.d.). How to create a wiki: Setting up a collaborative online workspace. ;Retrieved from https://www.mindtools.com/pages/article/how-to-cre…

• MindTools provides a practical overview of wikis, including their history and purpose, as well as how to build them.

BLOGS

Wolf, D. M., & Morouse, K. M. (2015). Using blogs to support informatics nurses’ curriculum needs. ;Online Journal of Nursing Informatics, ;19(2), 1–9.

• This article looks at the use of blogs and other online platforms to improve learning and communication, as well as patient care.

GOOGLE SITES

Refer to the following links to help you build your tool kit:

• G Suite Learning Center. (n.d.). ;Get started with Sites. ;Retrieved from https://gsuite.google.com/learning-center/products…
• Google. (n.d.). ;Google Sites. ;Retrieved from https://sites.google.com
• Google. (n.d.). ;Sites help. ;Retrieved from https://support.google.com/sites/?hl=en#topic=
• Resources for safety and improvement measures in geropsychiatric care. ;(n.d.). Retrieved from https://sites.google.com/view/safetyimprovementmea…

Also Read:

NURSFPX4020 Capella Assessment 3: Improvement Plan In-Service Presentation

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.

BUILDING PROFESSIONAL EFFICACY AND VISIBILITY

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

• This editorial urges nurses to be active contributors to ongoing research, journals, blogs, and other outlets to increase visibility of their valuable perspectives on health care.

EVALUATING RESOURCES

The Library of Congress. (n.d.). Evaluating Internet resources: An annotated guide to selected resources. Retrieved from https://www.loc.gov/rr/business/beonline/selectbib…

• This Web page collects resources related to evaluating the reliability and relevance of information from electronic sources. The format of this page may also be a helpful model for the resource list you are assembling.

BUILDING PROFESSIONAL EFFICACY AND VISIBILITY

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

• This editorial urges nurses to be active contributors to ongoing research, journals, blogs, and other outlets to increase visibility of their valuable perspectives on health care.

Root-Cause Analysis and Safety Improvement Plan Example

Root cause analysis (RCA) systematically and methodologically investigates an occurrence to identify the reason for a system failure that might not be apparent initially after the incident. System and personal failures can lead to patient safety risks, including medication errors (Center for Drug Evaluation & Research, 2019).

A root cause analysis was conducted to investigate an incident in the surgical postoperative unit that involved a morphine overdose. The purpose of this paper is to describe this incident, conduct a root cause analysis, and develop a safety improvement plan to prevent these occurrences in the future in the organization.

Root-Cause Analysis of Falls of Medication Errors

Charlie is a 20-year-old white female who had an emergency appendectomy three days ago due to acute appendicitis. Today, he still complains of severe pain at the incision site and the abdomen. During the review in the afternoon, his surgeon prescribed oral morphine 10mg Stat for his pain and documented that prescription in writing in the patient’s physical records. The same evening, four other patients were admitted from the operating room and post-anesthesia care unit (PACU).

RN, the day shift nurse in charge of the room, delegated the administration of morphine to a student nurse because she was attending to the new admissions. Charlie had been on IV painkillers in the first two days but showed suboptimal pain control. The student nurse picked IV morphine rarely used in the unit, and administered 10ml instead of the 10mgs prescribed by the surgeon.

The surgeon, who happened to be the head of the department of surgery, and the nurse manager in charge of the department agreed that a root cause analysis of the issue be done because there had been prior near misses in the last in the same department.

The RN discovered the issue on her hourly reviews when she noted that Charlie was becoming drowsy and confused and had vomited twice about half an hour after drug administration. The event necessitated the use of naloxone use to reverse the side effects of morphine overdose. A multidisciplinary care team was formed that monitored Charlie’s postoperative healing and recovery.

Analysis of Root Causes

The most common practice factors involved in medication errors include training, engagement, motivation, and work organization system. Interruptions commonly lead to medication errors by breaching the work organization system, thus increasing the risk of making medication errors of omission due to a break in concentrations (Schroers et al., 2022).

Possible outcomes are wrong medication, wrong dose, or wrong route in medication administration. Transitions in care provide a high risk of making medication errors. During this time, there are high chances of a break in the continuity of care, which can involve the patient medication lists.

Human factors contributing to the medication error included understaffing

Solution: