CAUSE ANALYSIS

Tina Marie Beltz

Main Discussion Post-Week 4

Medical errors unfortunately occur and are one of the main topics in the healthcare system.  It is continuously discussed because of the effect it has on patient care and outcomes.  The scenario this week involves a 20-bed medical unit at Downtown Medical.  This unit continues to have a high rate of medication errors even though they have implemented computer physician order entry, online nursing documentation, and barcode scanning.   The Institute of Medicine(IOM) defines a medical error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." (Singh G, Updated 2023 May 30)

A root cause analysis (RCA) team was developed at Downtown Medical to analyze adverse events from happening again.  The reason for a root cause analysis (RCA) is to analyze a problem, try to understand why the problem happened, and then find a way to prevent them from happening again (AHRQ, 2019) The team here at Downtown Medical consisted of a risk manager, a staff nurse, and a pharmacy technician.  Each member contributes in a different way and can bring different problem-solving technics to the team. (Spath, 2018)  The risk manager plays the role of mediator.  The staff nurse can explain how the medication is received and identify the steps that were completed in the 10 rights of drug administration.  At first, the nurse and pharmacist wanted to place the blame on the other, but the risk manager stepped in and explained that this team was about preventing further errors.

In the video, all members of the team began working together and finding the root cause of the medication error.  To put together a root cause analysis we need to know 3 things; what happened, why it happened, and what can be done to prevent it in the future.  RCA tool can help identify which parts in a process are faulty so they can be corrected. (Performance Health Partners, 2023)  One of the performance charts presented in this scenario was the Pareto chart.  The Pareto chart is a great tool to get the Root Cause Analysis started.  The Pareto chart is the chart that assesses the cause of the medication error, the Fishbone chart shows the cause and effect of errors that can occur in nursing and pharmacy, and the flow chart shows the medication administration process.

In the Pareto chart, it shows that defective scanners were the number one reason for medication errors.  The second reason was the look-alike sound-alike medications.  The third reason was pharmacy tech stress/errors.  To prevent these kinds of errors the facility should ensure that there are backup scanners that work and that the look-alike sound-alike medications are in separate locations and have distinctive markings.  As far as working short staff with high-stress levels, there definitely needs to be a big focus on hiring and preventing staff turnovers. 

 

References

AHRQ. (2019).  Root Cause Analysis. Retrieved from PSNet: https://psnet.ahrq.gov/primers/primer/10/Root-Cause-Analysis

Performance Health Partners. (2023, May 4).  Developing an Effective Root Cause Analysis in Healthcare. Retrieved from Performance Health Partners: https://www.performancehealthus.com/blog/developing-an-effective-root-cause-analysis

Singh G, P. R. (Updated 2023 May 30). Root Cause Analysis and Medical Error Prevention.  In: StatPearls [Internet]., https://www.ncbi.nlm.nih.gov/books/NBK570638/.

Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). In P. Spath,  Introduction to Healthcare quality management (3rd ed.) (p. 81). Chicago: Health Administration Press.