According to Groot (2021), root cause analysis allows healthcare organizations, practitioners, and policymakers to learn from previous medication errors or adverse events and prevent them from happening in the future, resulting in better patient care and treatment outcomes. Groot (2021) continues that recently approved regulations (ISQ1) have made root cause analysis compulsory for specific adverse events, making it significant for healthcare professionals to understand how to conduct the root cause analysis. Conducting the root cause analysis provides a systematic strategy to identify causes of medication errors and sentinel events to ensure that safety improvement is created to prevent recurrences.
Root Cause of the Administration of Medication to a Wrong Cancer Patient
According to Dorothy et al. (2021), the data review regarding medication errors in cancer patients reveals that 1-3% of patients encounter medication errors during treatment. In the U.S., medication error incidence is 7.1% in adults and 18.8% among pediatric patients (Dorothy et al., 2021). At the same time, Azim et al. (2019) report that 87.6% of medication errors occur at the prescription stage, while 31.4% are attributed to improper dosage. Medication administration to the wrong patient can lead to fatal consequences, including death. Azim et al. (2019) state that 99% of medication administration errors are preventable, especially with appropriate interventions. Wrongful drug administration can subject healthcare organizations to severe consequences, including legal battles and accusations of negligence that might taint the hospital’s reputation.
With the adverse consequences of wrongful medication administration, a root cause analysis was performed on the case reported by the practice nurse last month at the cancer center. The analysis aimed to understand the cause of administering the drug to the wrong patient at the facility. The analysis was conducted by a team of three experts, including a nurse, physician, and supervisor. The nurse recorded the case in the incident book, with the patient’s cause of death registered as a medication error.
In the primary care setting, nurses are prone to making grave mistakes that have significantly impacted patient lives. In most cases, nurses administer the wrong medication due to different factors, including burnout due to high workload, inexperience among nurses, and poor communication between the provider and the patient and among providers (MacDowell, 2021). The team reviewed two more cases of wrongful medication administration in the last year. Upon review, it was noted that more than 60% of the errors occurred because of increased workload that resulted in nurse burnout. According to Haddad et al. (2022), most medication administration errors arise due to a shortage of nurses. Specifically, the handover nurses were exhausted and might have handed over the wrong patient files or given incomplete instructions to the nurses taking over the ward rounds. At the same time, some of the cases were attributed to poor communication between nurses and patients and inexperience among the nurses. It was also noted that 50% of the wrongful drug administrations happened in the hospital’s cancer center, lifting the lid on the rising staff shortage and inexperience at the facility.
Additionally, 30% of the wrongful administrations might have been caused by writing mistakes, including using abbreviations for patient names and poor writing that may have resulted in massive confusion within the ward. The team also found some of the drugs sent to the wards had been labeled using abbreviations. This was a fundamental mistake because medicines may bear similar abbreviations with others, which might lead nurses to believe that they were administering the proper medication. Addressing these contributing factors is fundamental to eradicating wrongful drug administration at the hospital.
Application of Evidence-Based Strategies to Reduce Wrongful Drug Administration
With most of the wrongful drug administration occurring due to nurse shortage, it is essential to address personnel shortage to prevent burnout. In contrast, nurses and patients should be well-trained to impart pharmacological information. It is fundamental to illustrate that nurse staffing shortage leads to increased workload, burnout, and fatigue among nurses. The government and healthcare organizations should prioritize hiring more nurses to reduce the workload and limit medication administration errors.
Additionally, wrongful medication administration errors can be minimized by standardizing communication. According to MacDowell (2021), the healthcare system communication standards are primarily deployed to ensure proper medication is administered. The organization can introduce the tall man lettering on the electronic health records (EHR), with product labeling and resources on drug information used to alert nurses on the almost similar drug names (MacDowell, 2021).
The organization can also optimize the nursing workflow to limit potential errors. In most cases, wrongful medication can be attributed to distractors during the handover and administration process. It is fundamental to reduce interruptions when administering drugs and build a concrete safety check, which includes confirmation of patient and drug details before administering (MacDowell, 2021). It is significant to acknowledge the impact of technology in improving efficiency and accuracy in handling medication and administering the right drugs to the correct patients.
Improvement Plan
The improvement plan encompasses advancing nurse effectiveness and adjusting the organization’s technology, especially the HER. The first part entails enhancing the effectiveness and collaboration among nurses via improved and open communication, regular training, and establishing common team goals. Common healthcare goals and objectives include limiting waste, enhancing patient care, ensuring patient safety, and reducing response times. With mutual goals, nurses would be more focused on limiting common errors. Further, open communication and effective listening skills are also fundamental in eradicating medication administration errors. Nurses need to provide individual feedback, suggestions, and questions that can help improve care delivery. Nurses must also actively listen to patients to understand their needs and concerns to help them minimize errors. At the same time, Buljac-Samardzic et al. (2020) contend that regular training is required to improve the skills of nurses, especially communication and behavioral skills. Handover rules must also be implemented to curtail such occurrences in the future.
The second component of the plan involves improving the organization’s technology system to ensure seamless workflow. Reducing wrong medication administration requires a comprehensive and seamless HER system (MacDowell, 2021). For example, the organization should introduce the barcode medication administration (BCMA) technology to lower errors by deploying the barcode labeling of the medications, patients, and medical records for electronically connecting the correct medication dose to the right patient at the appropriate time (MacDowell, 2021). Research about non-timing medication errors within a system having barcoding technology revealed that the technology reduced medication errors by 41% and possible adverse drug event reduction by 51% (MacDowell, 2021). Thus, improving the facility’s technology system should be an appropriate strategy to lower medication errors.
Organizational Resources
Identifying and leveraging the present organizational resources is essential to implement the improvement plan successfully. The first component of the plan would involve using the expertise and skills of the existing, experienced staff to set goals and advance open communication among nurses and patients. However, training will require the organization to avail funds for hiring external quality improvement experts to provide specialized staff training. Again, the second part would involve using the expertise of the current IT team to improve the HER system. At the same time, barcoding will need the organization to outsource the technology, which will require sufficient funds. It is essential to note that leveraging existing resources will make it seamless for the organization to implement the improvement plan.
Conclusion
Wrongful medication administration has become a standard error in the healthcare system. The root cause analysis revealed that most wrongful medication administration mistakes occurred due to nurse burnout, poor communication, and writing errors like abbreviations of drugs and patient names. Addressing the staffing problem, improving collaboration, and enhancing the existing technology can help reduce such errors.
References
Azim, M., Khan, A., Khan, T. M., & Kamran, M. (2019). A cross-sectional study: medication safety among cancer in-patients in tertiary care hospitals in KPK, Pakistan. BMC Health Services Research, 19, 1-12. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4420-7
Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. (2020). Interventions to improve team effectiveness within health care: a systematic review of the past decade. Human resources for health, 18(1), 1-42. https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0411-3
Dorothy, A., Yadesa, T. M., & Atukunda, E. (2021). Prevalence of medication errors and the associated factors: a prospective observational study among cancer patients at Mbarara Regional Referral Hospital. Cancer Management and Research, 3739-3748. 10.2147/CMAR.S307001
Groot, W. (2021). Root cause analysis–what do we know? Journal of Accountancy and Business Economics, 95(1/2), 87-93. 10.5117/mab.95.60778
Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2022). Nursing shortage. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/
MacDowell, P. (2021). Medication administration errors. Department of Health and Human Services. https://psnet.ahrq.gov/primer/medication-administration-errors#:~:text=Wrong%20dose%2C%20missing%20doses%2C%20and,precautions%20in%20the%20outpatient%20clinic.
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