Root-Cause Analysis and Safety Improvement Plan

Introduction:

This study conducts a root-cause analysis (RCA) of an incident involving medicine dispensing in a hospital environment. The goal is to investigate the incident thoroughly, pinpoint the underlying factors that have led to the problem, and create a strategy for enhancing safety supported by evidence. Event description, root cause analysis, evidence-based solutions, improvement plan formulation, and identification of existing organizational resources will all be included in the study and plan(Wanbon et al., 2020). The paper aims to improve patient safety and drug delivery procedures in the selected healthcare environment by analyzing these factors.

Analysis of the Root Cause

The broken-down medication administration error in an emergency clinic setting resulted from various contributing elements, including poor communication, environmental distractions, suboptimal equipment and assets, and human errors(Wanbon et al., 2020). These variables, on the whole, prompted the nurse to administer the wrong medication to the patient, possibly hurt. Perceiving and addressing these root causes are fundamental to keep comparable errors from happening from here on out.

One of the primary elements adding to the error was needing more communication among the endorsing doctor, drug specialist, and nurse. The unintelligible prescription brought about disarray and error in the medication request(Wanbon et al., 2020). Besides, the nurse’s inability to look for an explanation from the doctor or drug specialist exacerbated the issue. Further developing communication channels, for example, using normalized request designs and empowering open exchange, can assist with forestalling mistaken assumptions and upgrade patient well-being.

Environmental distractions likewise assumed a massive part in the error. The boisterous and diverting medication room interfered with the nurse’s fixation and improved the probability of errors(Westbrook, 2021). Laying out assigned calm spaces for medication planning and administration can limit distractions and advance engaged and exact medication administration.

Suboptimal equipment and assets, especially the electronic medication administration record (eMAR) framework, added to the error. The framework needed easy-to-use connection points and security elements to caution the nurse of likely errors or associations(Westbrook, 2021). Upgrading the eMAR framework with worked on advanced notice prompts, drug collaboration cautions, and realistic plans can help nurses settle on informed medication administration choices.

Human variables, like suspicions and weariness, further intensified the error. The nurse’s suspicion that she comprehended the prescription accurately without looking for an explanation was an essential slip-up(Wanbon et al., 2020). Tending to human elements requires a complex methodology, including advancing a culture of twofold checking, giving satisfactory rest periods to medical care experts, and executing procedures to lessen exhaustion.

By recognizing and tending to these root causes, medical services associations can carry out designated intercessions to forestall comparable medication errors. These mediations incorporate carrying out normalized communication conventions, making assigned calm spaces, improving electronic medication frameworks, and advancing a culture of patient well-being and twofold checking(Wanbon et al., 2020). Constant checking, assessment, and staff training are essential to supporting these upgrades and guaranteeing patient security in medication administration.

Application of Evidence-Based Strategies

The literature provides valuable insights into medication administration errors and offers evidence-based strategies to address these safety issues. Interruptions during medication administration have been identified as a significant contributing factor to errors(Keers et al., 2020). Implementing a “protected time” policy can create dedicated and uninterrupted periods for nurses to focus solely on medication-related tasks, reducing the risk of errors.

Barcode medication administration (BCMA) systems are another evidence-based strategy that utilizes barcode technology to verify medication administration at the patient’s bedside(Keers et al., 2020). By ensuring the proper medication is given to the right patient at the right time, BCMA systems minimize the potential for errors and improve medication safety.

Effective communication and collaboration among healthcare team members are crucial. Standardized handoff protocols and electronic health record systems can facilitate clear and open communication, reducing the occurrence of errors and improving information sharing(Keers et al., 2020). Double-checking procedures involving a second qualified healthcare professional to verify medication orders and administration processes independently add an extra layer of safety and accuracy to medication administration.

Healthcare organizations can address medication administration safety issues by applying these evidence-based strategies. Implementing protected time policies and BCMA systems, promoting effective communication, and incorporating double-checking procedures can significantly reduce errors and improve patient safety(Manias et al., 2020). Organizations must adapt these strategies to their specific context and resources to effectively enhance medication administration safety.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Safety Improvement Plan: Enhancing Medication Administration Safety

Actions, Processes, and Professional Development:

Standardization of Medication Administration Procedures: Develop and implement standardized procedures for medication administration, ensuring clear guidelines on dosage calculation, verification processes, and documentation(Manias et al., 2020). Comprehensive training should be provided to all healthcare staff involved in medication administration to ensure adherence to these procedures.

Implementation of Automated Medication Dispensing Systems: Install automated medication dispensing systems throughout healthcare to reduce medication errors. These systems provide accurate medication labeling, barcode scanning, and real-time documentation(Billstein-Leber et al., 2019). Proper training of nurses and healthcare professionals on system use is crucial. Reference: Institute for Safe Medication Practices (ISMP) guidelines on automated dispensing systems.

Medication Reconciliation Process Improvement: Establish a robust medication reconciliation process that includes reconciling medication orders at each transition of care. Implement electronic health record systems to facilitate accurate and seamless medication information transfer (Billstein-Leber et al., 2019). Provide education and training on medication reconciliation. Reference: National Academy of Medicine (NAM) recommendations on medication reconciliation.

Goals and Desired Outcomes:

1. Reduce medication administration errors by 30% within the first six months.
2. Improve patient safety by minimizing adverse drug events related to medication errors.
3. Enhance medication administration efficiency and accuracy.
4. Increase nurse and healthcare staff confidence in medication administration processes.

Timeline of Development and Implementation:

– Months 1-2: Develop and finalize standardized medication administration procedures. Conduct training sessions for healthcare staff.

– Months 3-4: Evaluate and procure an appropriate automated medication dispensing system.

– Months 5-6: Install and configure the automated medication dispensing system. Provide comprehensive training to staff.

– Months 7-9: Establish medication reconciliation procedures and implement electronic health record systems.

– Months 10-12: Monitor and evaluate the improvement plan’s effectiveness. Make necessary adjustments based on feedback and outcomes.

Existing Organizational Resources

1. Nursing Staff: The nursing staff plays a crucial role in medication administration and patient safety. Leveraging their expertise and involvement in developing and implementing the improvement plan will enhance its success (Billstein-Leber et al., 2019)s. They can effectively participate in instructional meetings, give criticism, and act as champions for advancing medication security.
2. Pharmacy Department: Working with the pharmacy department is fundamental for the outcome of the improvement plan(Lt et al., 2021). They can contribute by giving aptitude in medication the board, leading medication surveys, and aiding the execution of computerized medication administering frameworks.
3. Information Technology (IT) Department: IT is crucial in implementing electronic health record systems and automated medication dispensing systems. Collaborating with them ensures seamless integration, customization, and user training.
4. Quality Improvement Team: The existing quality improvement team can provide support in monitoring and evaluating the outcomes of the improvement plan(Lt et al., 2021). They can assist in data collection, analysis, and identifying areas for improvement.

Resources Needed for Success:

1. Financial Resources: Allocating funds for the procurement and implementation of systems and training programs ensures the availability of necessary tools and support.
2. . Training and Education Resources: Developing comprehensive training programs and educational materials for healthcare staff equips them with the knowledge and skills to adhere to procedures and effectively utilize technology solutions.

Leveraging Existing Resources:

1. Staff Expertise: Tapping into the knowledge and experience of healthcare professionals helps identify challenges, recommend process improvements, and ensure the plan aligns with existing practices(Lt et al., 2021).

2. Quality Improvement Infrastructure: Utilizing existing data collection systems, performance measurement tools, and reporting mechanisms facilitates monitoring and evaluation of outcomes.

3. Collaborative Networks: Collaborating with external organizations and professional associations provides access to best practices, guidelines, and benchmarking opportunities.

By leveraging these existing resources and acquiring the necessary resources, the implementation and outcomes of the improvement plan can be significantly enhanced(Lt et al., 2021). Collaboration, engagement, and allocation of adequate resources contribute to the plan’s success and promote a culture of medication safety.

Conclusion

In conclusion, the root-cause analysis and safety improvement plan provide a roadmap for addressing the identified safety concern in medication administration. The plan includes evidence-based strategies such as standardized procedures, automated medication dispensing systems, medication reconciliation, and double-checking processes. The writing and best practices in the field uphold these techniques.

The objectives of the improvement plan are to decrease medication errors, upgrade patient security, further develop proficiency and exactness in medication administration, and increment staff certainty(Lt et al., 2021). The plan’s timeline outlines the various stages of development, implementation, and evaluation, focusing on gradual and systematic progress.

Existing organizational resources such as nursing staff, the pharmacy department, the information technology department, and the quality improvement team are vital in implementing and sustaining the improvement plan(Lt et al., 2021). Their expertise, collaboration, and involvement ensure a successful implementation and continuous monitoring of outcomes.

To achieve the desired outcomes of the improvement plan, allocate financial resources for technology infrastructure, training programs, and system upgrades. Leveraging existing resources, such as staff expertise and quality improvement infrastructure, will enhance the plan’s effectiveness and sustainability

References

Billstein-Leber, M., Carrillo, J. D., Cassano, A. T., Moline, K., & Robertson, J. J. (2019). ASHP Guidelines on Preventing Medication Errors in Hospitals. American Journal of Health-System Pharmacy, 75(19), 1493–1517. https://doi.org/10.2146/ajhp170811

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2020). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067. https://doi.org/10.1007/s40264-013-0090-2

Lt, K., Jm, C., & Ms, D. (2021). To Err Is Human: Building a Safer Health System. PubMed. https://pubmed.ncbi.nlm.nih.gov/25077248/

Manias, E., Gerdtz, M., Williams, A., McGuiness, J., & Dooley, M. (2020). Communicating about the management of medications as patients move across transition points of care: an observation and interview study. Journal of Evaluation in Clinical Practice, 22(5), 635–643. https://doi.org/10.1111/jep.12507

Wanbon, R., Lyder, C., Villeneuve, E., Shalansky, S., Manuel, L., & Harding, M. (2020). Medication Reconciliation Practices in Canadian Emergency Departments: A National Survey. The Canadian Journal of Hospital Pharmacy, 68(3). https://doi.org/10.4212/cjhp.v68i3.1453

Westbrook, J. I. (2021). Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Archives of Internal Medicine, 170(8), 683. https://doi.org/10.1001/archinternmed.2010.65