Week 4 Discussion Response- Improving Business Performance
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Week4DiscussionResponse-ImprovingBusinessPerformance.docx
Week 4 Discussion Response
Improving Business Performance
Colleague 1
Markeita Townsend
Hello everyone,
At Big City General Hospital, the alarming rise in reported medication errors requires a systematic approach to uncover underlying causes. Using the 5-Why tool and an effect-cause-effect logic tree, the task force conducted a structured root cause analysis to understand the systemic failures contributing to the problem.
Effect-Cause-Effect Flow Explanation
Problem (Effect): Increase in medication errors reported by nurses and pharmacists.
Why #1: Why are medication errors increasing? → Because staff are miscommunicating or mis administering medications.
Why #2: Why is staff miscommunication or misadministration occurring? → Because of inconsistent procedures and poor communication channels between departments.
Why #3: Why are procedures inconsistent and communication poor? → Because each department uses its own method for documentation and reporting, and there's no standardized process.
Why #4: Why isn’t there a standardized process across departments? → Because the hospital has not developed or implemented a unified medication protocol and training plan.
Why #5: Why hasn’t a unified protocol been developed and implemented? → Because rapid hiring and surging admissions have diverted attention from systemic policy updates and staff onboarding.
Root Cause Logic Tree Diagram (Effect–Cause–Effect)
This structured breakdown reveals two primary root causes:
1. Lack of standardized medication protocols and communication systems.
2. Inadequate training and cognitive overload due to staff shortages and high stress. Recommendations to Reduce Medication Errors
1. Implement a Hospital Wide Standardized Medication Protocol: Develop a unified procedure for medication administration and documentation across all departments. This includes integrated digital systems, daily communication briefs, and scheduled cross functional reviews.
2. Enhance Staff Training and Support Systems: Provide onboarding boot camps for temporary and new staff, focused specifically on medication safety. Reduce workloads through strategic staffing, mandatory breaks, and cognitive aids like checklists to offset stress related errors.
Conclusion
Big City General Hospital’s rise in medication errors reflects deeper systemic and human factors, not isolated incidents. The 5-Why analysis highlights the need for standardized procedures, improved communication, and structured staff training. By addressing these root causes, the hospital can significantly reduce medication errors and reinforce its commitment to patient safety.
References
iSixSigma Editorial. (n.d.). Determine the root cause: 5 whys. iSixSigma. https://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/Links to an external site.
Lean Enterprise Institute. (2018, July 19).
The 5 whys—lean problem solving [Video]. YouTube.
https://www.youtube.com/watch?v=SrlYkx41wEELinks to an external site.
Shook, J. (2009, Summer). Toyota’s secret: The A3 report. MIT Sloan Management Review, 50(4), 30–33.
Colleague 2
Lyndsay Camaroto
Hello,
Reviewing the provided description and concern identified by Big City General Hospital, it was noted that the identified problem which they would like to further examine would be an increase of medication administration errors. Lean Enterprise Institute (2018) discusses that in order to get to the 5 whys of root cause it is imperative to not only identify the problem but also to further break down the problem, as it will help you understand the work and find the point of occurrence.
In this situation the company was able to identify five potential factors that can be the “breakdown” of the problem, these factors individually may not be the root cause of the medication errors, but in collaboration with each other can impact the overall situation and further exasperate the situation. Reviewing how the five factors overlap, influence, or are the causation of one another, it is easy to see the trends and how one is playing into the next.
In this we can look at the identified problem:
Increased reported medication administration errors
Why? Over the past few months there has been a surge in patient admissions across the hospital and many departments.
Why has the increased admissions correlated to the increase in med errors?
This is highly impacting nurse to patient ratio as well as strongly impacting pharmacists as it is an increase of ongoing medications that need given, provided, or ordered for the additional admissions and patients. This can be directly seen in the longer working hours each member of staff is putting in and the increased level of stress that each person is exhibiting.
Why do heavier workloads and increased stress impact med errors?
When reviewing hours worked per staff member, there has also been an increase in overtime and staff that are working multiple 12-16 hours shifts a week. In past situations, longer working hours, less sleep, and increased work-related stress can be directly correlated to impaired decision making. This can be observed also in poor documentation, communication, and observation skills.
Why does impaired decision making impact med errors?
As mentioned, this can lead to forgetfulness or staff taking “short cuts” to do their job in order to get things done faster. There have been times when there is less communication than what is appropriate. This lack of communication can further create disconnection within departments, medication orders, dosages, and documentation. Poor communication can result in numerous consequences that could be detrimental to not only other staff but the patient as well.
Why does poor communication impact medication errors
One factor that has been identified is that each department has their own set of policies and procedures regarding medication administration and documentation, meaning that if not communicated properly among different departments, new staff, and temp staff, things can be overlooked and misunderstood. This is a large barrier that can be mostly contributed to the ongoing errors is that there is inconsistency on policies and procedures in the hospital as a whole.
Not having some sense of uniformity is preventing workflow from occurring effectively. A noted factor was improper training on new staff and temp agency nurses, can be correlated to the inconsistent factors of medication administration and documentation. If the entire hospital had one unformed policy and proper procedure there would be a notable reduction in medication errors, and also an increased in coverage staffing wise, as now you can have multiple staff transition or cover different departments, where as it was a barrier before because each unit operated differently.
References
Lean Enterprise Institute. (2018, July 19).
The 5 whys—lean problem solvingLinks to an external site.Links to an external site.
[Video]. YouTube. https://www.youtube.com/watch?v=SrlYkx41wEE
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Week4DiscussionResponse-ImprovingBusinessPerformance.docx
Week 4 Discussion Response
Improving Business Performance
Colleague 1
Markeita Townsend
Hello everyone,
At Big City General Hospital, the alarming rise in reported medication errors requires a systematic approach to uncover underlying causes. Using the 5-Why tool and an effect-cause-effect logic tree, the task force conducted a structured root cause analysis to understand the systemic failures contributing to the problem.
Effect-Cause-Effect Flow Explanation
Problem (Effect): Increase in medication errors reported by nurses and pharmacists.
Why #1: Why are medication errors increasing? → Because staff are miscommunicating or mis administering medications.
Why #2: Why is staff miscommunication or misadministration occurring? → Because of inconsistent procedures and poor communication channels between departments.
Why #3: Why are procedures inconsistent and communication poor? → Because each department uses its own method for documentation and reporting, and there's no standardized process.
Why #4: Why isn’t there a standardized process across departments? → Because the hospital has not developed or implemented a unified medication protocol and training plan.
Why #5: Why hasn’t a unified protocol been developed and implemented? → Because rapid hiring and surging admissions have diverted attention from systemic policy updates and staff onboarding.
Root Cause Logic Tree Diagram (Effect–Cause–Effect)
This structured breakdown reveals two primary root causes:
1. Lack of standardized medication protocols and communication systems.
2. Inadequate training and cognitive overload due to staff shortages and high stress. Recommendations to Reduce Medication Errors
1. Implement a Hospital Wide Standardized Medication Protocol: Develop a unified procedure for medication administration and documentation across all departments. This includes integrated digital systems, daily communication briefs, and scheduled cross functional reviews.
2. Enhance Staff Training and Support Systems: Provide onboarding boot camps for temporary and new staff, focused specifically on medication safety. Reduce workloads through strategic staffing, mandatory breaks, and cognitive aids like checklists to offset stress related errors.
Conclusion
Big City General Hospital’s rise in medication errors reflects deeper systemic and human factors, not isolated incidents. The 5-Why analysis highlights the need for standardized procedures, improved communication, and structured staff training. By addressing these root causes, the hospital can significantly reduce medication errors and reinforce its commitment to patient safety.
References
iSixSigma Editorial. (n.d.). Determine the root cause: 5 whys. iSixSigma. https://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/Links to an external site.
Lean Enterprise Institute. (2018, July 19).
The 5 whys—lean problem solving [Video]. YouTube.
https://www.youtube.com/watch?v=SrlYkx41wEELinks to an external site.
Shook, J. (2009, Summer). Toyota’s secret: The A3 report. MIT Sloan Management Review, 50(4), 30–33.
Colleague 2
Lyndsay Camaroto
Hello,
Reviewing the provided description and concern identified by Big City General Hospital, it was noted that the identified problem which they would like to further examine would be an increase of medication administration errors. Lean Enterprise Institute (2018) discusses that in order to get to the 5 whys of root cause it is imperative to not only identify the problem but also to further break down the problem, as it will help you understand the work and find the point of occurrence.
In this situation the company was able to identify five potential factors that can be the “breakdown” of the problem, these factors individually may not be the root cause of the medication errors, but in collaboration with each other can impact the overall situation and further exasperate the situation. Reviewing how the five factors overlap, influence, or are the causation of one another, it is easy to see the trends and how one is playing into the next.
In this we can look at the identified problem:
Increased reported medication administration errors
Why? Over the past few months there has been a surge in patient admissions across the hospital and many departments.
Why has the increased admissions correlated to the increase in med errors?
This is highly impacting nurse to patient ratio as well as strongly impacting pharmacists as it is an increase of ongoing medications that need given, provided, or ordered for the additional admissions and patients. This can be directly seen in the longer working hours each member of staff is putting in and the increased level of stress that each person is exhibiting.
Why do heavier workloads and increased stress impact med errors?
When reviewing hours worked per staff member, there has also been an increase in overtime and staff that are working multiple 12-16 hours shifts a week. In past situations, longer working hours, less sleep, and increased work-related stress can be directly correlated to impaired decision making. This can be observed also in poor documentation, communication, and observation skills.
Why does impaired decision making impact med errors?
As mentioned, this can lead to forgetfulness or staff taking “short cuts” to do their job in order to get things done faster. There have been times when there is less communication than what is appropriate. This lack of communication can further create disconnection within departments, medication orders, dosages, and documentation. Poor communication can result in numerous consequences that could be detrimental to not only other staff but the patient as well.
Why does poor communication impact medication errors
One factor that has been identified is that each department has their own set of policies and procedures regarding medication administration and documentation, meaning that if not communicated properly among different departments, new staff, and temp staff, things can be overlooked and misunderstood. This is a large barrier that can be mostly contributed to the ongoing errors is that there is inconsistency on policies and procedures in the hospital as a whole.
Not having some sense of uniformity is preventing workflow from occurring effectively. A noted factor was improper training on new staff and temp agency nurses, can be correlated to the inconsistent factors of medication administration and documentation. If the entire hospital had one unformed policy and proper procedure there would be a notable reduction in medication errors, and also an increased in coverage staffing wise, as now you can have multiple staff transition or cover different departments, where as it was a barrier before because each unit operated differently.
References
Lean Enterprise Institute. (2018, July 19).
The 5 whys—lean problem solvingLinks to an external site.Links to an external site.
[Video]. YouTube. https://www.youtube.com/watch?v=SrlYkx41wEE
