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

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1 Root-Cause Analysis and Safety Improvement Plan

Perla Rodriguez

Capella University Dr. Brandi Ballantyne

NURS-FPX4020: 2 Improving Quality of Care and Patient Safety June 13, 2022

1 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. 

1 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. 3 In less than 2.5 hours, a chest X-ray (CXR) revealed that the pleural catheter had been properly positioned, but the planned orientation of the Heimlich valve was inverted. In the end, the pneumothorax became larger and developed tension pneumothorax, which included a collapsed lung, full lung collapse, and a deep sulcus sign (Treiber & Jones, 2018). The Heimlich valve was reoriented by the doctors after spotting the problem. 3 A CXR showed that the pneumothorax and associated problems had been resolved after the valve repair. It was subsequently made clear to the patient and his family that a mistake had occurred. 

The occurrence was not only the result of a malfunction in the equipment utilized. The instructions and design of the device allowed for erroneous insertion, which was a contributing factor in the mistake. 3 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. 3 Because of the Heimlich valve's similarity to the adapter, the providers mistook it for a simple connector. 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. 3 As long as the patient's health remained stable and no emergency treatment was required, the factor could be managed. 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. 3The Heimlich valve instructions were not well given to the medical staff, either on labeling or in instructions. To prevent this from happening, the correct valve insertion policy should have been in place. 3 Instead of putting the patient's health in danger, the medical personnel should have closely followed the standards and informed any emergent difficulties to the team.  The patient's harm was caused by a lack of communication between the team members and incorrect device instructions. 

1 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 (Hibbert et al., 2018). 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 problem of medicine administration safety in the healthcare sector, which is normal practice (Mutair et al., 2021). 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 (Rodziewicz et al., 2021). 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 (Tariq et al., 2018). Standardized communication, adequate patient education, and improved nursing workflow are some of the best practices that may be employed to solve this problem. 

1 Improvement Plan with Evidence-Based and Best-Practice Strategies

3 Training, device design, and operator guidelines are the primary goals of the sentinel case. 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. 3 The Internet and data-based technologies should also be used to promote patient safety in the age of innovation. 

Following the case's precedent, a particular policy is needed. 3 Clear written instructions, particularly for new or infrequently used medical equipment, may help reduce technical problems. Improved usability and prescription safety need new labeling for current medications and devices (Treiber & Jones, 2018). 3 All medical gadgets should also be categorized into three risk categories.  All devices in classes 2 and 3 must undergo non-clinical testing in order to assess whether there is reasonable assurance of safety.  4 Class 1 devices are exempt from FDA requirements. 

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 (Rodziewicz et al., 2021). In the next week or so, policies will be introduced, and scenarios will be executed step-by-step according to this strategy. 

1 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 (Hibbert et al., 2018). 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 (Mutair et al., 2021). 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

1 Evidence-based procedures may help reduce drug mistakes and associated negative consequences, despite their rising incidence.  However, identifying the underlying reasons is an important first step in finding a solution.  This aids in the formulation of a focused strategy for resolving the problem.  Technology and effective leadership abilities may be used to increase the overall efficacy of care providers and patients by implementing an approach that focuses on both internal and external variables of care providers and patients. 

References

Hibbert, P. 1 D., Thomas, M.  J., Deakin, A., Runciman, W.  B., Braithwaite, J., Lomax, S., Prescott, J., Gorrie, G., Szczygielski, A., Surwald, T., & Fraser, C. (2018). 1 Are root cause analyses recommendations effective and sustainable?  an observational study.  International Journal for Quality in Health Care, 30(2), 124–131.  https://doi.org/10.1093/intqhc/mzx181 Mutair, A.  A., Alhumaid, S., Shamsan, A., Zaidi, A. R. 1 Z., Mohaini, M.  A., Al Mutairi, A.,.  & Al-Omari, A. (2021). 1 The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems.  Medicines, 8(9), 46.  https://doi.org/10.3390/medicines8090046

Rodziewicz, T. 1 L., Houseman, B., & Hipskind, J. E. (2021). 1 Medical error reduction and prevention. StatPearls [Internet]. 1 https://www.ncbi.nlm.nih.gov/books/NBK499956/ Tariq, R.  A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). 1 Medication dispensing errors and prevention.  https://europepmc.org/article/NBK/nbk519065

Treiber, L. 1 A., & Jones, J. H. (2018). 1 After the medication error:  Recent nursing graduates'  reflections on adequacy of education.  Journal of Nursing Education, 57(5), 275-280.  https://doi.org/10.3928/01484834-20180420-04

NURS-FPX4020_007780_1_1223_OEE_33 - NURS-FPX4020 - SPRING 2022 - SECTION 33

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Perla Rodriguez on Mon, Jun 13 2022, 7:18 PM

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