Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan

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Root-Cause Analysis and Safety Improvement Plan

Perla Rodriguez

Capella University

Dr. Brandi Ballantyne

NURS-FPX 4020: Improving Quality of Care and Patient Safety

June 14, 2022

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Root-cause Analysis

Today, patient safety still needs ongoing, evidence-based reforms that eliminate existing

health care system flaws. Analyzed will be pharmaceutical mistakes that occur at Villa Health

Facility as a sentinel event. For the last six months, this patient safety issue has worsened, resulting

in increased pharmaceutical occurrences. Countermeasures are welcomed after the most recent

event indicated that the situation had deteriorated to the point of no return. The purpose of this

study is to discover the core reasons for the considerable prevalence of drug errors. An evidence-

based approach to reducing pharmaceutical mistakes will also be presented to prevent this from

happening in the future.

Analysis of the Root Cause in the Administration of Wrong Dosages

Emergency personnel was called to an emergency room by a trainee following an

admission of an autistic patient experiencing dyspnea. A chest X-ray was ordered since the patient

denied any previous trauma or fever. After the chest tube was inserted, the air began leaking from

all the 14 catheters used. The Heimlich valve was employed to close the air leak in the chest

drainage device. However, the Heimlich valve was not positioned properly even after the patient’s

pleural catheter was fixed by the nurse following chest X-ray procedure. In the end, the

pneumothorax became larger and developed tension pneumothorax, which included a collapsed

lung, full lung collapse, and a deep sulcus sign (Hagley et al., 2019). The Heimlich valve was

reoriented by the doctors after spotting the problem. After performing the instantaneous CXR

procedure, it was concluded that patient’s problems are resolved through needle decompression

and the placement of a chest tube. It was subsequently made clear to the patient and his family that

a mistake had occurred.

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The occurrence was not only the result of a malfunction in the equipment utilized but

instead, the mistake occurred due to malfunction of the device that the nurse did not understand the

instrument’s guidelines. The instructions for the gadget did not include a process control feature or

a test for proper orientation. Human error, on the other hand, had a significant impact on the

outcome. Valve knowledge and practical abilities were lacking among the medical professionals.

The provider’s experience was with simple connector contrarily to the available complex Heimlich

adapter available in the facility. The environment in which the medical operation took place was

also a part of the event's setting. The emergency department received an urgent presentation of the

patient's condition. it would have been easier to manage the prevailing harm condition if the patient

was stabilized to a normal state. A more thorough investigation of the gadget's workings might

have been done, or a more recognized tool could have been employed.

Communication issues, both verbal and written, may have contributed to the occurrence.

The provider stated that the mistake occurred because the Heimlich valve labelling and instructions

were unclear. To prevent this from happening, the correct valve insertion policy should have been

in place. to keep the life of the patient safe and service delivered to be of quality, the provider

should have informed the medical team in the emergency department who perhaps are acquainted

prescription standards. Poor labelling of equipment and miscommunication amongst the team

accelerated or caused the patient’s harm.

Application of Evidence-Based Strategies

According to prior research, pharmaceutical delivery errors are most often the result of a

lapse in following the standard treatment management procedures (Martin-Delgado et al., 2020).

The improper drug, the wrong dosage, the wrong timing, and the inappropriate mode of

administration are just a few examples. All of these root cause factors have exacerbated the

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problem of medicine administration safety in the healthcare sector, which is normal practice

(Sarfati et al., 2019). Errors in drug administration and treatment, as highlighted in recent research,

are part of a more complicated pharmaceutical process that requires multidisciplinary teams

working together to provide high-quality patient-centered care (Hagley et al., 2019). Medication

mistakes are more likely to occur when doctors and patients are unable to effectively communicate

and educate each other about their medications. By addressing the current care gaps that contribute

to medical administration mistakes, strategies may be implemented to solve the safety problem of

medication administration errors (Hagley et al., 2019). Standardized communication, adequate

patient education, and improved nursing workflow are some of the best practices that may be

employed to solve this problem.

Improvement Plan with Evidence-Based and Best-Practice Strategies

In this sentinel situation, the EBP improvement plan should comprise educating the

provider about the Heimlich valve instructions, understanding how the device design work and

educating the provider about the risk of equipment mishandling. A program of required education

and well-defined instructions is needed to address the underlying causes of human knowledge-

based concerns. It is likely that the training of the employees might at least reduce or eliminate the

risk of mistakes. Also, following advancement of technology, the provider should use internet and

data- based technology devices.

Following the case's precedent, a particular policy is needed. Importantly is developing

ways technical problems should be reduced either by educating the provider about infrequent used

medical devices or having clear written guidelines about prescription. Improved usability and

prescription safety need new labeling for current medications and devices (Martin-Delgado et al.,

2020). Handling of facility’s medical equipment should be categorized into three risk strata. First

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category are 1st class devices that are not approved by the FDA. Importantly, to test the quality and

safeness of all second- and third-class devices, they must undergo non-clinical testing.

Education and gadget design should be integrated and used in real-world emergency

situations, as well. They should be designed to teach personnel how to use certain medical gadgets

and improve their collaboration and cognitive abilities. To reduce the danger of device abuse and

fight the fundamental cause of communication difficulties, an emergency simulation might be used

(Sarfati et al., 2019). In the next week or so, policies will be introduced, and scenarios will be

executed step-by-step according to this strategy.

Existing Organizational Resources

Villa Healthcare's staff, including nurses, medical technicians, doctors, and other members

of the healthcare supply chain, are actively involved in efforts to enhance the plan's execution and

results (Mummadi et al., 2020). Mandatory training for all employees should include additional

medication and gadget supplies to give materials for practice, increasing the equipment cost.

Materials, employees, finances, and buildings related to the delivery of high-quality health care

services may be required as organizational resources to ensure the plan's success (Stolic et al.,

2022). As a result, human resources (resources for work), capital (resources for cost), and material

assets (material resources) are all necessary components of this strategy. These organizational

resources are sufficient to carry out the plan's recommendations to the end.

Conclusion

Numerous patients suffer and even die due to medical errors in the medical field and the

management of their treatment. Due to the close interaction with patient care and administration,

healthcare providers such as nurses are extremely vulnerable. Errors in medication administration

may result from different factors, including but not limited to poor provider-patient

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communication, insufficient resources, individual characteristics, and a lack of training.

Prescriptions may be improved in terms of readability and order standardization by using this tool

to reduce medication mistakes and spoken commands. The plan's execution will be aided by the

addition of additional medical experts and training resources.

References

Hagley, G., Mills, P. D., Watts, B. V., & Wu, A. W. (2019). Review of alternatives to root cause

analysis: developing a robust system for incident report analysis. BMJ open quality, 8(3),

e000646.

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J.

(2020). How much of root cause analysis translates into improved patient safety: A

systematic review. Medical Principles and Practice, 29(6), 524-531.

Mummadi, S. R., de Longpre, J., & Hahn, P. Y. (2020). Comparative effectiveness of interventions

in initial management of spontaneous pneumothorax: a systematic review and a Bayesian

network meta-analysis. Annals of Emergency Medicine, 76(1), 88-102.

Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., ... & Rioufol, C. (2019).

Human‐simulation‐based learning to prevent medication error: A systematic

review. Journal of evaluation in Clinical Practice, 25(1), 11-20.

Stolic, S., Ng, L., Southern, J., & Sheridan, G. (2022). Medication errors by nursing students on

clinical practice: An integrative review. Nurse Education Today, 105325.