FPX 4020 Capella University Safe Medication Administration Presentation

attachment_2Root-Cause Analysis and Safety Improvement Plan

Andhony Rivera

NURS-FPX4020

Capella University

January 1, 2021

Root-Cause Analysis

Healthcare and medicine are some of the most vital aspects and components of human life. People get sick and they seek treatment from the various healthcare facilities within their area of residence. Some might need specialized care. However, there are some instances where the healthcare facilities and the various healthcare professionals can experience errors that affect the patients. In the recent past, Clarion Court Nursing Facility has experienced an increase I n the number of medication errors that occur within the facility. Some cases are serious in that they result in the overdosing of the patients which has the potential to become fatal. Completing a root cause analysis can help in identifying the causes behind the medication errors and also help in devising and implementing an improvement plan to improve the safety of the patients in the facility. A root cause analysis serves to identify areas that need improvement in terms of patient safety (Haxby & Shuldham, 2018).

Analysis of the Root Cause

The nursing professionals at the healthcare facility comprise of CNAs, LPNs, and RNs. There are specific nursing professionals who have the obligation or mandate of delivering the medication to the patients. In the last year, there has been a significant rise in the number of medication errors in the care facility. One case saw a patient overdose that can have devastating effects for all the parties involved. Such incidences have warranted the application of a root cause analysis to improve patient safety in the care institution.

According to the World Health Organization (2016), medication errors refer to any avoidable and preventable event that has the potential to result to inappropriate medication that might cause patient harm while the medication is in the control of the consumer, patient, or healthcare professional. The organization further explains that the events can relate to the method of medication prescription, the healthcare products, professional practice among other things. The healthcare professionals working in the healthcare facility discovered the near overdose during a bedside shift change. The nurse that took over the shift discovered that the patient was unresponsive to the attempts of the nurse to arouse him. After extensive investigation into the issue, the discovery was that the patient had received an extra dose of oxycodone. The interim nurse had administered pain medication after the patient requested for it as he was in pain.

Unfortunately, the interim nurse did not did not document the administered medication. The primary nurse assigned to the patient on the other hand was on a lunchbreak and upon returning to the patient, administered another dose at the request of the patient who has dementia. The request was not less than an hour later after the first administration. According to Makary and Daniel (2016), it is not possible to completely eliminate human error, however, the relevant people and authorities can study the problem and develop a safer system of doing things.

The root cause analysis conducted in the institution sought to identify the recent increase in medication errors. The main objective of the analysis was to understand why the medication errors have been on the rise and identify the issues that cause the medication errors.

The person in charge of conducting the analysis interviewed the various nurses in the facility from different shifts. They obtained important information from the interviews that contributed or served to explain the rise in the medication errors. Some of the information that came up from the interviews include things such as poor listening among the nursing staff. Another thing is that there is a high rate of turnover in the facility and the new employees are not conversant with the residents in the facility. Another observation was that the charting system in use in the facility is challenging to use and causes some of the nurses that have not mastered its use to fall behind.

Communication is also an issue in the organization with the LPNs stating that there is lack of proper communication that leads to some not having all the necessary information on a patient. A response from the RNs showed that it was difficult finding a balance between meeting the needs of the patients, keeping up with their various duties and following the appropriate protocol. The interviews also indicated that the staff feel that the facility does no have the appropriate number of employees, leaving the ones that are currently there feeling overburdened, overworked, and exhausted. All these are some of the factors that can result in medication errors in healthcare facilities. According to Tawfik et al. (2018), all the identified factors are independently associated with significant medical errors.

Evidence from research indicates that there are a lot of factors that can result in medical errors. These factors include things such as medications having improper labels, poor communication on the part of the healthcare professionals working on a specific case, distractions, exhaustion, and missing patient information among others. In this case, the cause of the medication error was lack of proper communication and documentation on the part of the nurses assigned to the resident. The primary nurse was unavailable when the patient required pain medication. As a result, the interim nurse who was still getting familiar with the various processes administered the medication and failed to document it on the patient chart. The primary nurse upon arrival administered the same dose as requested by the patient who has dementia and has no recollection of receiving the medication earlier.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Understaffing, poor communication, unfamiliarity with eh residents, and large patient to nurse ratios were the main factors that contributed to the increase in medication errors and near patient overdoes in the facility. These factors all pose various patient safety concerns. Many of these errors occurred in cases involving patients with cognitive impairments.

There are various strategies that the facility can put in place to address the issue of medication errors. The improvement plan should include things such as putting in place an automated medication dispensing machine. According to Risør et al. (2018), automated medication dispensing machines have the potential to greatly reduce medication errors. It also serves to improve patient safety. Another alternative that can be combined with the automated medication dispensing machines is barcode scanning of the medication. Nurses that fail to scan the medication will be liable and face disciplinary actions as the facility will monitor the scans. The facility can also create a quality improvement program that will comprise of the various nurses in the facility, the charge nurse, and the director of nursing. These members will meet regularly and strategize on the various ways that they can improve patient safety and quality of care. Implementing an SBAR tool would help address the issue of communication as it would offer immediate access to relevant patient information. According to Stewart (2016), the tool enables all users to communicate through a common structure. Finally, the improvement plan should also include a strategy on how to increase the staff numbers to better accommodate the number of residents in the facility to reduce exhaustion and large patient to nurse ratios.

Existing Organizational Resources

Some of the resources that the organization requires include state of the art technology, more human resources within the facility among other things. However, the facility already has some resources that it can leverage to ensure that the improvement plan is a success. For instance, the facility has various nursing professional that can e a part of the quality improvement team. It can set aside a room within the facility that will serve as a meeting place for the team where they can meet and hold discussions to try and find a way forward. The facility will require additional resources such as stationery and projectors for the meetings as well as hiring additional staff among other things.

Conclusion

Medication errors are a common but a highly preventable issue in the US medical system. There are various factors that lead to medication errors and they include things like understaffing, poor communication among other things. Conducting a root cause analysis can help a healthcare facility identify the factors and develop an appropriate improvement plan.

References

Haxby, E., & Shuldham, C. (2018). How to undertake a root cause analysis investigation to improve patient safety. Nurs Stand, 32(20), 41-46.

Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353.

Risør, B. W., Lisby, M., & Sørensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. International Journal for Quality in Health Care, 30(6), 457-465.

Stewart, K. R. (2016). SBAR, communication, and patient safety: an integrated literature review.

Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., … & Shanafelt, T. D. (2018, November). Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. In Mayo Clinic Proceedings (Vol. 93, No. 11, pp. 1571-1580). Elsevier.

World Health Organization. (2016). Medication errors. World Health Organization.