Redo Assessment 3-Class 3

October, 2020

Root-Cause Analysis

A Structured Root Cause Analysis (RCA) is becoming a key area of interest among health professionals. Hospitals are performing this to reduce surgical errors are some of its subspecialties. Recent research has helped in the RCA process and how effective they can implemented in the formal quality improvement projects (Charles et al, 2016). The purpose of an RCA is to design ways that will formally address the issues in an organization. This utilizes a methodology that helps in causal identification and development of corrective actions. In the case of reducing of medical errors, it will be on the root causes and contributing factors, actions can be developed to prevent recurring errors. The paper describes and analyzes medical errors and discusses evidence-based strategies to provide quality patient care in medical and surgical practice. It will define measures that intervene for planned success in patient safety and the success of the RCA.

The use of medication is a multifaceted process in a healthcare setting starting with the physician giving a prescription, nurses performing transcription, pharmacists dispensing, administration of the medication, and monitoring of patients. Medication errors are a primary cause of most deaths and unintended patient harm. According to Feleke et al., (2015), medication administration errors results in patient morbidity, unfavorable drug events, mortality, and increases the duration of hospital stay for the patients. Additionally, it increases healthcare costs for the healthcare system and the clinicians. According to IOM and joint commission, drug administration errors can be averted by evaluating the extent and the accompanying factors of drug administration errors. This will help improve the quality of patient healthcare.

Bearing in mind the adverse effects of medication administration errors in patients, a root-cause analysis on the medication administration errors cases reported over the years was conducted at the inpatient hospital unit. The analysis objective was to understand the causes of medication administration errors in inpatient patients in the hospital unit. A group of ten experts took the initiative to conduct the analysis; they included physicians, nurses, pharmacists, and quality and safety improvement staff. A team of registered nurses had done cases of medication administration errors that had been reported within the facility. All the medication administration error cases were described to be due to wrong prescription, medication labelling, miscommunication of order, wrong dosage, wrong dispensation, and poor communication between patients and physicians.

It was discovered that most of the medication errors occurred during the medication administration phase, when nurses had a lot of work to do due to understaffing. The experts reported that physician’s prescription was a significant cause of medication administration errors. They recorded that physicians prescribed the wrong dose, the wrong quantity, wrong indication, or even prescribed contraindicated drugs to a patient. Further, they noted that lack of prescribed drug knowledge, the recommended dosage, and the details of the patients contributed topmost of the prescription errors. The experts also reported that medication administration errors due to dispensation were mainly because pharmacists selected medications with the wrong strength or wrong drug mainly with medications bearing a similar name or drugs that look alike. For instance, drugs such as Lasix and Losec when handwritten, look alike.

The experts went through the reports and noted that approximately 24% of dispensing errors occurred in the inpatient section. Moreover, the medication administration errors reported in the inpatient hospital unit involving the nurses were primarily due to transcription errors (manual and electrical transcription of orders). In these omission errors, the nurses do not administer drugs due to specific reasons. According to their report, transcription errors involved incorrect medication, time, frequency, dose, oral order misunderstanding, oral orders not fed into the system, discrepant orders from the patient’s medication history, and incorrect scheduling of doses in manual administration record (Gorgich et al, 2016).

Application of Evidence-Based Strategies

. Organizations need to spell out, clearly, health guidelines regarding patient safety and medical errors. They need to ensure that accountability is reinstated on the hospitals and the health professionals (Scott & Henneman, E. (2017). Seamless need to develop appropriate systems that help in addressing medication errors. For instance, critically ill patients need more attention and often cause a burden to the limited staff. Separating the patients helps assign the need for urgency and critical care. It will minimize medical errors for those in a critical state.

According to Dall'Ora et al., (2016), physical exhaustion and emotional exhaustion contribute to the errors. The interruptions during medication administration increase the risk of medication errors (Berlin, 2017). The nurses need work and life balance to be better placed at being at their optimum. Staff engagement measures are one way of ensuring that their concerns towards patient safety and medical administration in these departments are prioritized. Medication administration errors are multifaceted issues, and solving them requires a multilateral solution.

Considering that all the reported medication administration errors occurred because of the errors in prescription phase, it is essential to install computerized physician order entry to reduce the incidences of the prescribing errors, which will avoid errors in the other phases. Besides, clinical decision support systems is another critical intervention that can be utilized to reduce medication errors (Gorgich et al., 2016). They help reduce medication errors by alerting and helping prescribers’ choices regarding therapeutic management, a period of drug therapy, allergy, laboratory test values, dose, frequency, and side effects, which are very vital to guarantee patient safety.

Using the clinical decision support systems are significant because they conduct the patient's background check, provide timely information, and provide feedback on the cost and suitability of medications. Incorporating personal digital assistants is vital in reducing medication errors because several medication errors are because pharmacists and physicians lack the appropriate medication knowledge.

The personal digital assistants would help provide the physicians and the pharmacists with medication information required for prescribing, distributing, and counselling (Wang et al., 2015). It will also provide the physicians and pharmacists with access to the patient's specific treatment profile, which is essential in reducing prescription and transcription errors. Additionally, modified medication and prescription charts and mobile clinical assistants can be used to reduce medication errors. Physicians can make their handwritten prescription legible, use automated dispensing machines, and use of smart devices when administering drugs intravenously.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Safety and quality improvement plan is an integral approach in helping healthcare professionals achieve maximum levels of safety performance. The improvement plan comprises of two-split approaches, i.e., enhancing the efficiency and coordination of the healthcare professionals and implementing the physical modifications. First, the improvement plan aims at improving the knowledge of healthcare workers regarding medication errors, reporting, and avoiding them (Gorgich et al., 2016). In addition, due to the understaffing, the plan focuses on increasing the number of healthcare professionals to avoid overworking that causes burnout, which results in medication errors.

Second, the plan aims at ensuring there is proper communication between the healthcare professionals when medication is involved, which will help reduce the miscommunication issues (Wang, 2015). It is also crucial for the nurses to educate the patients on the medications and allow them to open up regarding their medical history, allergies etcetera. Third, the improvement plan aims at ensuring healthcare providers utilize evidence-informed practices. Finally, regarding the physical modifications, the plan focuses on the implementation of advanced medication administration technologies that minimize these medication errors.

Acquisition of knowledge is critical in health care. The nurses need to be trained to understand their changing roles in preventive care (Charles et al., 2016). They need to realize the ethical implications of medication error and their relative contribution to the same. They need to know the right procedures to undertake when reporting medication errors and how best the hospital serves its needs. Such improvement plans need the adoption of new EHR technologies. Hospitals need to train their workforce to adopt new technology.

Adopting new technology, such as EHR, helps identify medical errors and trace those liable for accountability. This will also build on the awareness of the reporting procedures and process. They also get informed on medication error reporting policies and systems within the organization reducing the excuses for ensuring accountability. Also, it is the role of the hospital to define work division. This minimizes work overload and disruptions during surgical operations. There need to be defined as guidelines targeting critical departments such as surgical. Training should focus on the implementation of policies and medication management for overall improvement in quality care. This should be implemented for over two months.

Existing Organizational Resources

For the program plans to be a success, the organization needs to set aside resources. This will require budgeting, which will target: increasing staffing, training measures, and purchase of up to date EHR software systems. Specialists need to be brought on board to assess the current needs of the organization. Also, the training and education of the staff need to be a continued measure of the organization. It allows them to improve their knowledge of patient safety and keep up with current standards of their practices in reducing medication errors. Accomplishing this plan will require approximately $50,000.

Conclusion

Performing an RCA process is all about identifying the consequence of events that led to

the event investigated. In this case, patient safety has been targeted to those in the surgical and transplant department. As a critical department in the healthcare setting, special consideration will be put in place in its complexities. The categories that will focus are human errors, communication, policies, and procedures leading to such issues. The goal of a sustained system should also give room for improvement. Elimination of medical errors promotes patient safety. Quality improvement measures are targeting surgical errors.

References

Berlin, L. (2017). Medical errors, malpractice, and defensive medicine: An ill-fated triad. Diagnosis, 4(3), 133-139. doi:10.1515/dx-2017-0007

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10(1), 20-20. doi:10.1186/s13037-016-0107-8

Dall'Ora, C., Griffiths, P., & Ball, J. (2016). Twelve-hour shifts: Burnout or job satisfaction? Nursing Times (1987), 112(12-13), 22-23.

Feleke, S. A., Mulatu, M. A., & Yesmaw, Y. S. (2015). Medication administration error: Magnitude and associated factors among nurses in ethiopia. BMC Nursing, 14(1), 53-53. doi:10.1186/s12912-015-0099-1

Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016;2015;). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 54448-54448. doi:10.5539/gjhs.v8n8p220

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046.

Scott, S. S., & Henneman, E. (2017). Underreporting of medical errors. Medsurg Nursing, 26(3), 211.

Wang, H., Jin, J., Feng, X., Huang, X., Zhu, L., Zhao, X., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: A trend analysis during the journey to joint commission international accreditation and in the post-accreditation era. Therapeutics and Clinical Risk Management, 11, 393-406. doi:10.2147/TCRM.S79238