root cause analysis

Root Cause Analysis at Downtown Medical

Background Information

The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient's assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.

Who should be asked to participate in the RCA?

Select the people from the list below

Information Technology

No, however, information technology should be included in the quality management meeting.

Pharmacy Supervisor

No, however, the pharmacy supervisor should be included in the quality management meeting.

Pharmacy Technician responsible for filling the unit dose machine

No, this individual would be interviewed by the RCA team to determine the process for filling the unit dose machine and what might have happened to contribute to the error.

Education Coordinator

No, the education coordinator would not participate in any of the meetings. This person might be asked to help with staff education if that is a recommendation from the RCA team.

Risk Manager

Yes, the risk manager should chair the RCA team, as the position is responsible for identifying threats to patient safety.

Compliance Officer

No, the compliance officer is responsible for assuring the facility follows accrediting agency standards and would not be included in any of the meetings.

RN who administered the medication

No, but this individual would be interviewed by the RCA team to determine what happened that led to the medication error.

RN who works fulltime on the unit

Yes, this person will provide needed expertise on the medication administration process and use of the barcode medication administration equipment.

Purchasing Agent

No, the purchasing agent is responsible for purchasing equipment and supplies and would not know about the medication administration process.

Chief Financial Officer

No, however, the CFO should be included in the quality management meeting.

Chief Executive Officer

No, the CEO will receive the final report and recommendations and should not be included in any of the meetings.

Nurse Executive

No, however, the NE should be included in the quality management meeting.

Director, Quality Management

No, however, the QM Director will chair the quality management meeting.

Pharmacist who told the nurse to administer the medication

No, but this individual will be interviewed by the RCA team to determine what happened that lead to the medication error.

Pharmacy Technician who works fulltime in the pharmacy

Yes, the pharmacy technician can provide information on how the medication-dispensing machines are filled.