Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan 

The Root Cause Analysis of Medication Errors Example

Introduction

The root-cause analysis refers to the systematic approach used to identify the causes of given adverse events or problems to facilitate response identification to prevent further escalation of the problem. The paper focuses on the root-cause analysis as used in the identification of the medication errors that have rapidly increased in geriatric patients at Miami Nursing Home. The facility has experienced a surge in medication errors through drug overdose and administration of wrong drugs to patients in the facility. The problem has been linked to staff errors and system problems in the organization. The major purpose of the paper is to demeanor the root-cause analysis on medication errors as well as develop a safety improvement plan by incorporating evidence-based healthcare strategies and resources in the organization to address medication errors.

The Root-Cause Analysis of Medication Errors at Miami Nursing Home

The surge in medication errors has been reported in the facility, leading to serious adverse events that would have otherwise been prevented. The consequences of medication errors such as prolonged length of hospital stay, increased cost of healthcare, and patient harm has led to an increased level of dissatisfaction and reduced profits in the organization. The most affected patients in the facility are geriatric patients due to their multiple morbidities and the consequences of polypharmacy when inexperienced staff fails to consider drug interactions and the ability of the patient to eliminate the drug due to reduced organ function (Hibbert et al., 2018). There have been more cases of adverse drug reactions that would have been avoided that cause more readmissions and higher morbidity and mortality. The most common effects observed in the medication errors are nausea and vomiting, headache, changes in blood pressure, impaired consciousness, confusion, sweating, and falls. The serious medication errors that have prompted intense patient treatment in the intensive care for close monitoring have accounted for about 10% of cases with life-threatening outcomes.

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The factors that cause medication errors in the facility are staff negligence and improper communication among healthcare providers. The inability of nurses to adhere to the rights in drug administration has been significantly attributed to medication errors. The root-causes analysis done revealed that the rights in drug administration such as the right patient, route, dose, time, and medication were neglected in several instances leading to improper prescription, administration, and medication monitoring. The staff working under pressure to meet datelines or those distracted have failed to follow the procedures in drug administration (Billstein-Leber et al., 2018). Also, the improper use of technology by erroneous electronic record keeping and communication as well as faulty equipment have been attributed to the increased rate of medication errors in the facility. The improper drug communication caused by constraints and distractions has caused medication errors as staff fails to adhere to drug administration.

Evidence-Based Strategies Used in Reducing Medication Errors

There are diverse evidence-based and based practices strategies used to decrease the risk of medication errors and optimize interventions in drug administration. These include robust staff training on drug administration, implementing medication reconciliation, and utilizing the health information technologies in drug management. The use of computerized order entry systems, electronic health systems such as e-prescriptions, barcode scanning, and automated drug dispensing cabinets are effective technological strategies that can be effectively used to reduce medication errors (Jember et al., 2018). The avoidance of medication errors during patient admission, shifts, and discharge can be accomplished through medication reconciliation in the healthcare system.  The failure in communication or the use of appropriate technology in medication management increases medication-related problems that cause adverse events and compromised patient safety. According to Hibbert et al. (2018), over 40% of reported medication errors are caused by impaired medication reconciliation in various care transitions.

The successful quality improvement initiative in medication management is proper staff training and education to improve inter-professional communication and collaboration in medication management. Healthcare staff should be adequately trained on safe drug management to increase efficiency in drug administration hence improving patient safety. The creation of guidelines on drug administration for healthcare providers and the provision of continuous training to enhance the experience of healthcare providers on drug administration is useful in improving the safety of drug administration (Billstein-Leber et al., 2018). The education of healthcare providers to adopt open communication and embrace teamwork enables them to share ideas in inpatient management thus promoting better healthcare outcomes. The provision of continuous health education to healthcare providers promotes the inculcation of collaborative healthcare practices in drug administration including, responsibility, accountability, assertiveness, cooperation, and respect in various patient management dynamics.

Improvement Plan for Safe Medication Administration

The successful management of medication administration is essential to improve patient safety by reducing medication errors. The improvement plan encompasses the installation of information technology systems such as computerized order entry systems, electronic health systems such as e-prescriptions, barcode scanning, and automated drug dispensing cabinets. Also, staff should be adequately trained on medication safety practices to prevent medication errors. The use of e-prescriptions, barcode scanning, and automated drug dispensing cabinets will enable healthcare providers to adhere to drug administration procedures in drug administration hence boosting patient safety and efficiency in patient management Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example. According to Billstein-Leber et al. (2018), the use of information technology offers numerous opportunities to transform medication management through decreasing human errors, facilitating healthcare coordination, improving drug administration efficiency, promoting data tracking, and improving the overall clinical outcomes. The healthcare team should be adequately trained on the use of technology in drug administration to facilitate effective implementation in program usage to lower medication errors.

The use of e-prescribing, barcode scanning, and automated drug dispensing cabinets enable healthcare staff to adhere to effective medication administration procedures through the systematic nature of modern technology that guides individuals to adopt the rights in drug administration. For instance, the administration of medications at the wrong time or to the wrong patient would result in an electronic message alert to prevent the healthcare provider from proceeding with drug administration thus preventing the occurrence of drug-related errors (Jember et al., 2018). The above interventions have significantly lowered the rate of medication errors by controlling drug dispensation, tracking drug distribution, and promoting the identification of drug errors for prompt patient management. The use of barcode scanning should be embraced in the healthcare system since they are more reliable and faster compared to physical data entry. Also, computerized order entry systems enable providers to efficiently input entries as well as review changes rapidly to promote safe drug administration through alert reminders in drug review programs.

Existing Organizational Resources

The useful organizational interventions that can promote patient safety in medication management include good leadership strategies and effective communication. The healthcare leadership has taken the central role to enrich the working environment by promoting team in service delivery. The proper leadership fosters care coordination that ultimately leads to quality improvement in various healthcare practices including medication management. The organizational resources that could be leveraged to improve patient safety in medication administration include the existing technological base and continuous medical education programs. The continuous medical education program facilitates in-service training for healthcare providers on strategies to reduce medication errors and induction in the effective use of technology (Hibbert et al., 2018). The existing computer network will be used to incorporate the installation of information technology systems such as computerized order entry systems, electronic health systems such as e-prescriptions, barcode scanning, and automated drug dispensing cabinets. Also, the existing training programs will be useful in educating staff on the appropriate policies and procedures in drug administration to promote patient safety.

Conclusion

In summary, there has been an increase in medication errors in healthcare facilities leading to serious adverse events that would have otherwise been prevented. The factors that cause medication errors in the facility are staff negligence and improper communication among healthcare providers. The improper use of technology by erroneous electronic record keeping and communication as well as faulty equipment has been attributed to the increased rate of medication errors in the facility. The use of robust staff training on drug administration, implementing medication reconciliation, and utilizing the health information technologies in drug management is effective in reducing medication errors. The organizational resources that could be used to improve patient safety in medication administration include good leadership strategies, effective communication, an existing technological base, and continuous medical education programs.

 References

Hibbert, P. D., Thomas, M. J., Deakin, A., Runciman, W. B., Braithwaite, J., Lomax, S., … & Fraser, C. (2018). Are root cause analyses recommendations effective and sustainable? An observational study. International Journal for Quality in Health Care, 30(2), 124-131.

Billstein-Leber, M., Carrillo, C. J. D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC nursing, 17(1), 1-8.

 

Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example

For this Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example 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. Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example 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.
  • Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example
• 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 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 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 a root cause of a specific safety concern in a health care 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 health care setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to 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 Capella University NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan – The Root Cause Analysis of Medication Errors Example
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