Capella 4020 Assessment 2

Capella 4020 Assessment 2 : Root-Cause Analysis and Safety Improvement Plan

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Capella University

Capella 4020 Assessment 2

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Date

Root-Cause Analysis and Safety Improvement Plan

Root-cause analysis (RCA) is a technique that emerged in the healthcare domain which is used to examine the direct and indirect risk factors for a preventable adverse event as well as establish a safety plan (Martin-Delgado et al., 2020). A patient safety issue about a medication administration error took place at the Vila Health facility. This paper will explore more on the root causes of the sentinel event considering the elements that led to the issue. Moreover, an evidenced-based safety improvement plan will be established following the available resources of the organization so that these issues can be prevented in the future.

Root-cause analysis of medication administration errors

Hazardous medication practices are one of the leading factors for preventable patient harm in healthcare systems and the biggest proportion of these malpractices occurs in the administration phase where nurses are primarily responsible (Wondmieneh et al., 2020). As illustrated in assessment 1, Simi is a clinical nurse with 15 years of bedside experience who works at Vila Health facility. On a busy shift, Simi wrongly administered the antibiotic Piperacillin/Tazobactam 100 mg dose of another patient to Mrs, Goldsmith who was allergic to the drug. After receiving Pip/Tazo, she developed a severe anaphylactic reaction with the symptoms of redness, itching, and high-grade fever. The doctor was informed and an anti-histamine was immediately administered to stop the symptoms from aggravating however, the medication administration error committed by the nurse was a highlighting concern here. Research identifies that poor quality of care and unsafe practices can lead to high morbidity and mortality among patients (Kruk et al., 2018) hence it is important to identify the factors leading to the problem and immediately plan a safety improvement model against them.

The root-cause analysis for the medication administration error event identified factors that cause these sentinel events. The preventable factors are:

Non-adherence to rights of medication:

Every nurse receives basic knowledge about the five rights of medication administration in their training. However, there are circumstances where nurses do not follow this framework hence resulting in medication errors. A study identified that due to non-adherence to the rights of medication, 32.6% of errors accounted for due to wrong time administration and 30.5% were because of administering to the wrong patient (Salami et al., 2019).

Excessive workload and burnout:

An unacceptable nurse-to-patient ratio causes an increased workload for nurses eventually leading to various medical errors. The study showed that in most hospitals the nurse-to-patient ratio is around 1:10/12 which is why the nurses are overburdened hence there are increased incidences of medication errors. Another reason for the increased workload is the shortage of nurses which ultimately results in unintentional medication errors (Ratanto et al., 2021). Further evidence from the research indicates that burnout results in 43.3% of nurses being distracted during medication preparation hence 90% of nurses reported that this results in incorrect administration of the drug (Boutou et al., 2021).

Lack of updated training:

Continuing professional education (CPD) is constantly updating your professional knowledge. Authors state that CPD is essential for nurses to have lifelong learning and to update their knowledge and skill according to the time and trends (Mlambo et al., 2021). Additionally, research also documented medication errors due to incomplete training reports for 78.7% of cases (Tsegaye et al., 2020). This information reveals that when nurses have minimal knowledge of drugs, they may cause errors in administering the drugs without noticing the adverse events that the patient may survive hence patients’ safety is impaired (Escrivá Gracia et al., 2019).

Poor nurse-patient collaboration:

Nurses and patients together play important role in preventing medication errors. Nurses when providing complete information about medications to their patients, patients are well-aware and can stop any incorrect administration by nurses. This study concludes that there must be a balance established between nurses and patients so that responsibility can be shared and transferred from nurses to patients to prevent medication errors (Jeong & Park, 2022).

These elements contributed to the happening of the Vila Health facility case. In the case presented above the elements which played a major role is non-adherence to the right of medication (wrong patient) and nurses’ workload. Simi already had a busy shift because of which she couldn’t concentrate on her work which is why she didn’t identify the patient correctly. Thus, administered the drug even without checking its appropriateness. Moreover, another important element is incomplete training. Since Simi was a senior nurse with an experience of 15 years, she might have limited knowledge about current trends and practices therefore she didn’t check the appropriateness as well as didn’t follow the six rights of medication. Lastly, in the case of the Vila health facility, if the nurse had informed her patient that the medicine is Pip/Tazo, the patient would have stopped her before administering by probing her to check because she is allergic to the drug.

Evidenced-Based and Best Practice Strategies

The evidence-based strategies that can be used to eradicate medication administration errors are the utilization of the five rights of the medication administration framework and hiring nurses to reduce workload.

Rights of medication framework:

These are the five rights of medication administration. These rights were established to reduce the prevalence of medication administration errors. The five “R” are the right patient, the right drug, the right dose, the right time, the right frequency, and the right route (Jones & Treiber, 2018). It is evident that the implementation of the rights of medication administration enables nurses to become accountable for their actions and the administration process becomes legitimate with standard protocols. Study shows that 40% of medication errors are due to administration hence improvement in human (nurses) behavior related to medication administration is important. Adherence to medication administration guidelines is important for medication safety (Mula, 2019).

Hiring new nurses:

Another strategy is hiring new nurses which is essential to immediately address the workload and to avoid compromising patient care (Maresova et al., 2020). This plan will not only benefit nurses and the organization but it will also help in improving patient outcomes by decreasing workload and preventing medication errors (Lukewich et al., 2022).

Safety improvement plan

The improvement plan includes two approaches, one is to effectively implement the five rights of medication in nursing education and clinical practice and the other one is to retain old or hire new nurses by creating a budget plan.

To implement the five rights of medication, it is important for nurse educators to frequently train nurses using in-service sessions. A distraction-free zone should be created and there must be silence in each medication room so that nurses can concentrate on their medication administration (Salami et al., 2019). Moreover, a barcoded identification system should be established within the electronic medication administration portal so that the correct identification of the drug and patient is ensured.

Another safety improvement plan is to retain present nurses or hire new nurses by keeping a budget that will utilize some of the organizational finances. Based on nurses’ salaries in the US, the lowest salary for an individual graduate nurse is around $39,000 per hence keeping in mind the requirement of nurses at least 5-6 nurses can be hired for the individual department in the hospital. Recruiting nurses and training them requires more finances hence studies advocate the importance of retention of nurses rather than hiring new ones (Opinion et al., 2021). Retention strategies like increasing salaries and providing other benefits such as medical allowance from the hospital will help in reducing nurses’ brain drain hence decreasing the workload on present nurses.

Organizational resources

The types of resources that will be utilized to implement this plan are human and financial resources. Some of the ways that current organizational resources can be utilized are by retaining present nurses. Encouraging nurse leaders to promote a positive working environment with open lines of communication will motivate current staff toward their jobs, decreasing stress and burnout and eventually improving patients’ outcomes in terms of safe administration practices. Effective communication methods for example active conversation with the nursing staff results in enhanced employee commitment to the profession and improved satisfaction levels (Walker & Hirsch, 2020) thus nurses are less likely to commit medical errors. Moreover, studies have identified that nurses who are supported by their managers and are engaged positively are more likely to be loyal to their organization thus improving patient care outcomes (Opinion et al., 2021).

The EMA systems of the hospital can be leveraged by adding barcoded systems so that effective and safe medication practices are ensured. The Barcode medication administration system supports nurses in correctly identifying patients and preventing identification issues of medication administration. This system enables healthcare facilities to also fulfil one of the goals of JCIA standards of patient safety (Rodziewicz et al., 2022). Some of the organizational financial resources should be utilized for hiring new nurses as proposed in the safety improvement plan according to the budget. All of these organizational resources will impact positively safe medication practices however, retaining current employees or hiring new nurses to decrease workload has a major potential impact on improving medication errors and promoting safe medication administration.

Conclusion

Root-cause analysis is a method for determining the factors that led to sentinel events. This root-cause analysis on medication administration errors identified factors like non-adherence to the right of medication, workload, nurses’ burnout, poor nurse-patient collaboration, and lack of training. It is essential to implement a safety improvement plan so that these factors can be eradicated and safe medication practices are followed to improve patients’ outcomes.

References

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