Root Cause Analysis

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RCA PAPER: MEDICATION ERRORS

Student Name

Nursing Department, Normandale Community College

NURS 2950: Leadership in Nursing

Mary Maine

Date

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RCA Paper: Medication Errors

Medication administration errors (MAE) are events that all healthcare professionals deal

with. It is said that all nurses will commit a medical error in their career. The hope is that it will

be one that will not cause harm to the patient. In my own experience as a nurse’s aide there has

been a range of medication errors, from administering half of the required dose of calcium, to

neglecting documentation of an administration, to double dosing a patient on a beta blocker, to

administering all twenty-four hours of a client’s medications in one administration. Good

examples to invite the reader to continue

Consequences of MAEs can vary from no noticeable problem to substantial harm to the

client. In an article by Ohio Nurses Review (2016) they report that nurses witness many

medication errors and often no harm is done while at other times the client is harmed. MAEs that

do not cause harm are not noticed, however, it does not matter if an error does not have a

harmful consequence. All medication errors need to be taken seriously and reported to avoid

further errors. According to Hammoudi et al. (2017), the vast majority of MAEs occur from

previously neglected reporting and correcting of smaller errors. Neglecting to report and correct

problems leads to bigger problems and subsequently, larger consequences. In this analysis an

example of a fatal MAEs in a long-term care facility will be examined including, what lead to

this error in medication administration, what leads to common MAEs, and what strategies can be

implemented to prevent errors. Nicely presented

MAE in a Long-Term Care Facility

During an evening shift at a long-term care facility, the nurse on duty was an LPN agency

nurse. Although she was not a regular nurse at this facility, the nurse had worked at the facility

several times and was familiar with the medication administration policy and procedures. During

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the evening medication pass the LPN was in with an elderly woman (Resident #1) preparing her

medications when she was called away to another resident who was asking for assistance. She

left and assisted the other resident. When she returned, she began to administer what she thought

was resident #1’s medication. The resident stated that she had never taken “purple pills” before

and questioned the administration. The nurse assured her that the medication was correct and the

resident took the pills. About an hour later she was found by an aide unresponsive. The LPN

came to find her with a thready pulse and shallow respirations. She called 911. When the

paramedics arrived, they administered Narcan, which instantly revived the resident. She was

taken to the hospital; on the way she told the paramedics that the nurse “had given her 4 purple

pills” and that she had fallen asleep after taking them. During her stay at the hospital the resident

came in and out of consciousness with the administration of Narcan, but ultimately did not

survive (NSO, 2020). Concise description provides the reader with enough background to

understand why this issue is important

Causes of MAEs

The literature reports that some of the most common causes of MAEs are: interruptions,

staffing issues, problems along the medication chain, and workplace culture and communication.

Nurses in long-term care facilities are often required to be multitaskers, balancing multiple tasks,

performing cares and skills, while ensuring patient safety. This second sentence further clarifies

the introductory sentence. Wonderful Tasks with high stakes such as medication administration

require a habit of undivided concentration. Flynn et al. (2016) emphasizes the importance of

concentration by stating the high levels of critical thinking and concentration needed for a safe

medication pass. Medication administration takes time, critical thinking and concentration,

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however according to Ohio Nurse Review (2016), medication administration is one of the most

frequently interrupted tasks in nursing.

In an article by Hammoudi et al. (2017) nurses report that insufficient staffing promotes

interruptions and adversely affects safety. Inadequate staffing necessitates frequent position

changes and subsequently, shifting concentration. This adds to distraction, contributing to

MAEs. yes

The next contributing factor discussed is the medication chain. To err is human. This is

seen in the medication chain. Vermeulen et al. (2017) states that errors can happen in various

stages of the medication process: the provider can make an error in writing the prescription, the

pharmacy in preparation or delivery, or an error can occur in the administration. The nurse is

often the last line of defense against errors and so is held accountable for errors in administration

(Taylor, 2012). But the actual cause of the harm to a patient may originate anywhere in the

process of providing medications and every healthcare worker involved shares responsibility

(Taylor, 2012). Well written

The problems found in the medication chain signifies another problem, which is a lack of

a culture of safety. This deficiency is evidenced by the type of distractions that occur. Some

distractions seem more acceptable, such as a patient needing care, which is a common

interruption in medication administration (Flynn et al., 2016). The amount of concentration

needed for medication preparation needs to be recognized however. All of the preparer’s

attention must be devoted to that moment in time as if every medication pass was someone’s life

hanging in the balance, because it is. Frequently the types of interruptions are other nurses

engaging each other while one is preparing to administer medications. Flynn et al. (2016) notes

that a common interruption is nurses interrupting each other with unrelated topics of

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conversation. These types of interruptions are a clear indicator that a culture of safety is lacking.

A deficit in a culture of safety does not stop at nurses. For there to be a cultural change everyone

involved must be committed to safety. This includes the whole chain of medication production.

Nurses alone will not correct problems embedded in an interprofessional process. Hammoudi et

al. (2017) states that common factors in MAEs among nurses come from further up the

medication process, such as an error in transcription, packaging, or even communication.

Another indicator of a culture lacking in safety is negligence of medication error reporting.

Adverse effects have been seen to occur as a result of not reporting small errors in medication

administration (Hammoudi et al., 2017). Medication error reporting prevents injury. For

example, a nurse administering medications may see an order that is contraindicated for a client

because of a change in condition and holds it but does not contact the prescribing provider to

have the order changed. Negligence of reporting this may be detrimental the following day when

another nurse gives the medication without questioning, leading to harm to the client. Many

nurses face fears about disciplinary action or losing their job which discourages the reporting of

errors. According to Hammoudi et al. (2017) “The main barriers to the reporting of errors by

nurses were related to the administrative response, fear of reporting and disagreements regarding

the definitions of errors” OK (p. 1038). There are obstacles to reporting errors but the

consequence of not reporting them is too great to be ignored. If the nurse in our previous

scenario had reported the contraindicated medication, she would have prevented her fellow nurse

from making the error the following day. This act of reporting may not have been for herself but

rather for the whole team and ultimately, for the safety of the client.

Analysis of possible causes

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From the review of the literature, it is seen that MAEs are complex problems. Analysis of

the contributing factors of the death of resident #1 from a morphine overdose will now be

examined. The three major contributing factors to this MAE were distraction during medication

administration, failure to follow the rights of medication administration, and failure to receive

input from the client. The delay of naloxone, also called Narcan, administration will also be

discussed.

Being the nurse in a long-term care facility can be hectic. It feels like one is pulled in all

directions. This sets a nurse up for distraction and interruptions. This is what is seen in this story.

Although the LPN on duty had worked at that facility several times, she was not a staff nurse

there. This factor is important because it means the LPN was not familiar with the residents and

their medication. The evening medication pass is a busy time. Although the LPN was familiar

with the procedures of medication administration at the facility, she was distracted by an aide

requesting that she help another resident. The LPN steps away in the middle of a medication pass

for resident #1. A distracting environment is not a circumstance that the LPN could control;

however, she did have choices in the other two factors. As nurses we choose how we administer

medications, if the order is checked, and whether to listen to the client when they question our

judgement. The NSO article, that tells this story of the morphine overdose, describes one

medication right as documenting contemporaneously, or simultaneously, to the administration of

medication (NSO, 2020). This means avoiding premature documentation and not waiting on

documentation of medication administration. It seems the LPN did not complete this right, if she

had, she likely would have caught her error. Excellent, you clearly communicate the complexity

of the issue

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Finally, the LPN failed to verify the right patient, and administered the incorrect

medication. In recommendations for safe practice the NSO states the importance of listening to

client’s concerns and verifying orders before proceeding, which was neglected (NSO, 2020).

Resident #1 questioned the medication, but the LPN did not verify that it was correct.

Naloxone, the antidote to morphine, was not given until the paramedics arrived. Where

morphine is administered there should be access to the antidote, however it seemed it was not on

site or the LPN was not familiar with the protocol.

Figure 1

Fishbone Diagram; Causes of Medication Errors Fantastic

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This diagram displays the factors that led to this error. Harm to clients usually involve

elements of the environment, the people, and their individual practices, the processes set up, the

management, the materials and the equipment that one is working with. When harm to a client

occurs, it is usually a combination of several factors that add up to the event, in this case, the

untimely death of an elderly lady. Good summary

Solutions

When looking at the various factors involved in MAEs there are multiple elements that

need to be addressed. These elements include: individual responsibility as nurses, improvements

to the work environmental, and thoughtful system changes. Ideally, these changes will provide

consistency and compensate for the aspect of human error that will always be present. For

instance, every person involved in the medication chain should be dedicated to the safety of their

clients. Every action regarding medications should be approached, by each individual, with

vigilance. Problems still arise however. If the problem of maintaining vigilance throughout years

of medication administration is corrected there may still be problems if the work culture is

fraught with interruptions that are considered normal and a medication chain leaves room for

human error. Changes need to be made at all levels, not simply individual.

It has been found that adding computerized checks to the medication administration

process can help eliminate human error. It is unknown what kind of order the LPN had access to,

it is probable that it was a paper medication administration record (MAR). This system of

medication administration could be improved. In an effort to reduce human error the barcode

system has been implemented in many practices. This is described in the Taylor (2012) text as a

computerized system in which it is required that the nurse scans the patient’s wristband and the

medication. In this way it is more difficult to commit MAEs. This solution may not be affordable

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for the facility. There are other strategies that they could implement that would be affordable. In

the story incomplete rights of medication administration and distraction were key factors that led

to this error (NSO, 2020). To promote the three checks and five rights of administering

medication being completed every time the facility could mandate yearly education. This would

allow all staff to review proper medication administration, be observed for habits that could lead

to MAEs, be educated on the importance of reporting all MAEs and on the importance of

finishing medication administration before continuing on to the next task. There should be follow

up on this measure. Weekly auditing could be completed by alternating staff of paper MARs to

check for proper documentation. The facility could also track reported medication errors to see if

the yearly education is effective. In an article by Flynn et al. (2016) they found that

implementing quiet zones or wearing an indicator that they should not be interrupted, such as a

hat, was effective in decreasing distractions. This would also promote a culture of respect for the

medication administration process.

While consistent staffing is not always possible it should be the goal of long-term care

facilities. It allows relationships to grow between staff and residents, positively affecting care

both psychosocially and physiologically. It promotes trust and communication between the

caregiver and resident. The familiarity could decrease MAEs, if the LPN on duty had been

familiar with the resident, she would likely have remembered that resident #1 did not take

morphine. She also may have been more likely to recheck the medication.

Finally, it is unknown if the facility had naloxone on site. It was not given until the

paramedics arrived. Either the LPN did not know the procedure for morphine overdose or

naloxone was not on site. To correct this the facility would provide naloxone on site and provide

education for all staff.

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Throughout this paper we have seen the importance of safely administering medications

and what contributes to MAEs. While safe medication administration is every individual’s

responsibility, systems problems contributing to MAEs need to be evaluated. Improvement in

interprofessional communication, and cultures that reflect the importance of safety should be

seen as the result of careful assessment and implementation of error proofing tactics.

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References

Flynn, F., Evanish, J.Q., Fernald, J.M., Hutchinson, D.E., Lefaiver, C. (2016). Progressive care

nurses improving patient safety by limiting interruptions during medication

administration. Critical Care Nurse, 36(4), 19–35. https://doi-

org.ndcproxy.mnpals.net/10.4037/ccn2016498

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. https://doi-org.ndcproxy.mnpals.net/10.1111/scs.12546

NSO Insurance – Learning - Individuals – NSO®. (2020). Retrieved December 16, 2020, from

https://www.nso.com/risk-management/individuals?ViewAll=true

Taylor, C., Lynn, P., Bartlett, J. L. (2012). Lippincott CoursePoint for Taylor: Fundamentals of

Nursing. (9th edition). (pp. 834-838). Wolters Kluwer. Retrieved from

https://coursepoint.vitalsource.com/#/books/9781975101336/

Vermeulen, J. A., Kleefstra, S. M., Zijp, E. M., & Kool, R. B. (2017). Understanding the impact

of supervision on reducing medication risks: an interview study in long-term elderly care.

BMC Health Services Research, 17, 1–10. https://doi

org.ndcproxy.mnpals.net/10.1186/s12913-017-2418-6

Waiton, B. (2016). Are you prepared to prevent medication errors? Ohio Nurses Review, 91(4),

17–27.

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