In the healthcare industry, medication administration errors are an unfortunate reality, and the topic has been continually explored due to its grave impact on patient care and outcomes. Medication administration errors can lead to major undesirable consequences for clinicians, patients, and families. Even though it may be challenging to determine the definitive causes of medication administration errors in particular situations, it is essential to assess strategies that can be utilized in mitigating and preventing adverse events that may arise from such errors. A root cause analysis can provide a valuable resolution for clinicians and patients to further comprehend and prevent medication administration errors and combat further occurrences. According to Martin-Delgado et al. (2020), a root cause analysis is a useful tool for identifying the immediate and remote causes of safety incidents. By determining the root causes, healthcare organizations can make systemic changes and implement corrective actions to minimize the likelihood of adverse events and future occurrences. This assessment analyzes medication administration errors and explores evidence-based strategies to address this safety issue and identify a safety improvement plan that healthcare professionals can adopt to reduce the likelihood of such errors.
Analysis of the Root Cause
A root cause analysis of medication administration error for a patient admitted to the emergency department who had been struck by a car was conducted. In this personal experience, LifeFlight was dispatched, and I was the nurse in charge; upon arrival at the accident scene, the patient was connected to RWJ’s ALS monitor. Since the patient was agitated, LifeFlight performed intubation and agreed to 100mg of ketamine and 100mg of rocuronium, which was administered by my colleague. Prior to and following the intubation, it was observed that the patient’s BP was elevated, and since the patient was agitated before intubation, the team suspected that the patient might have had a head injury. We decided to hold off giving ketamine for post-sedation, and instead, a dose of 100mcg of fentanyl was given and also a 5mg of versed after the patient was transferred into the aircraft.
Care was transitioned to Jersey Shore, and it was then discovered that the narcotic count in the scene bag contained two ketamine and no succinylcholine vials. The count was supposed to be one ketamine and one succinylcholine. I then asked my colleague whether our current vials of ketamine were a 500mg/10ml vial or a 200mg/10ml vial, and he said he thought we had a 200mg vial at one point. However, I was certain we had 500mg/10ml of ketamine, but in my mind, I thought it was 200mg, which I was not sure until 18 hours passed. I then realized that I had grabbed the wrong vial and contacted Jersey Shore to inform them that I may have made a medication error. I had removed the 200mg/10ml of succinylcholine and not the 500mg/10ml of ketamine. My colleague stated he was sure that he had administered ketamine to the patient, but he reminded me that I had said, “I have ketamine 20mg/1ml and drawn up 5ml making 100mg.” Therefore, He was not able to verify the label and confidently say what the vial contained since RWJ ALS providers were between us. It was now understood that the concentration of 20mg/ml would have been for succinylcholine and not for ketamine.
Our pharmacy never separated high-risk medications like paralytics as all medications were kept in the same spot; hence we overlooked the actual medication names. In this scenario, the patient ended up getting a dose of succinylcholine rather than the intended dose of ketamine since I grabbed the wrong vials. Our patient was not wearing a helmet at the time of the accident, and therefore he had likely suffered a head injury. A wrong dose of succinylcholine would potentially increase intracranial pressure, which can be detrimental to the patient. Even though, at first, we had secured the patient’s airway, the wrong dose of succinylcholine could impair the ability to maintain an open airway due to prolonged muscle paralysis.
In the above scenario, the ground medical team was required to administer the correct dose of ketamine to the patient. However, we ended up drawing the wrong dose of succinylcholine hence making a medication administration error. This would have led to severe consequences for the patients as well as the healthcare organization. The medical team was required to verify if the correct vial was drawn, but since the medication names were overlooked, human factors contributed to this safety issue. In addition, the patient was surrounded by a group of medical teams, and it was challenging trying to identify what the medication bag contained; thereby, I assumed I had taken the correct vial, which my colleague had no time to verify. Suppose the medical team had given my colleague and I adequate space, in that case, we would have administered the correct medication. As a result, human factors were the underlying causes of the medication administration error.
Application of Evidence-Based Strategies
Safety issues are a significant health concern and can lead to a severe impact on patient well-being and outcomes. Healthcare organizations are designed to provide treatment and care for patients; however, different factors can lead to safety risks, potentially resulting in harm to patients, medical errors, and adverse events. Interruptions and distractions during medical administration, like urgent tasks, alarms, and phone calls, can divert the attention of health professionals, increasing the likelihood of errors (Kavanagh & Donnelly, 2020). Also, poor medication packaging and labeling such as packaging that make it challenging to differentiate between medications and confusing or unclear labels increase the risk of medication administration errors. For instance, our medications lacked proper labels, hence making it challenging to differentiate between different vials. We failed to perform independent verifications and double-checks, which led to the error we made. Furthermore, look-alike medications, like those with similar packaging, can pose safety issues due to confusion. As a result, clinicians can potentially administer the wrong medication. Healthcare organizations should address these factors by adopting various strategies, such as fostering a culture of safety and improving communication and collaboration.
Strategies like improving communication and collaboration when administering medication can prevent medication administration errors. Implementing tools like read-back and verification promotes accurate and clear information exchange between clinicians and thus ensures the correct medication is administered. Fostering a culture of safety encourages health professionals to prioritize patient safety and also report medication errors without fearing any form of retribution. This involves developing reporting systems for such errors, performing comprehensive investigations, and utilizing information acquired to implement system-level improvements (Mutair et al., 2021). Further, ensuring that health professionals undergo training regarding medication administration is essential. This may include training on proper medication handling, medication safety principles, familiarity with high-risk medications, and calculation skills, which are vital for reinforcing safety practices.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The improvement plan involves standardizing medication administration processes and improving medication packaging and labeling. First, developing standardized procedures and protocols for medication administration ensures clarity and consistency for clinicians (Kavanagh & Donnelly, 2020). The procedure should outline the steps of medication administration, such as verification processes, dosage calculation guidelines, and documentation required. Besides, a checklist-based approach should be implemented for medication administration that ensures all necessary steps are followed. Further, the medication administration workflows should be streamlined to minimize distractions and disruptions during the medication administration process. This process can take approximately one month to allow an interdisciplinary team to develop and review the standardized process, including checklists, protocols, and communication guidelines. Implementing standardized processes and checklists ensures adherence to best practices and increased accuracy, hence reducing medication errors.
Secondly, improving medication packaging and labeling enhances clarity and readability to avoid picking the wrong medication (Simas da Rocha et al., 2021). This includes labeling guidelines and medication order formats. In the healthcare organization, all vials require added stickers for labeling to distinguish induction agents (ketamine) from paralytics (rocuronium) since all these were stored in the same spot. Besides, new medication should be ordered in separate boxes to avoid confusing vials. Ensuring the information on labels is conspicuously displayed, like the medication name, dosage instructions, strength, precautions, and warnings, helps clinicians avoid administering the wrong medication. Labeling medications and adding stickers is an effortless process that can take a few days, and communicating with suppliers to ensure new medications are packaged in separate boxes. Overall, proper labeling and packaging prevent confusion and ensure clinicians satisfy the “Five Rights” of medication administration.
Existing Organizational Resources
For standardizing the medication administration process, personnel resources like the quality improvement team are required to drive improvements and change. They play a crucial role in implementing the plan, monitoring progress, assessing data, and determining areas of further improvement. Besides, healthcare leaders in the facility can support the improvement plan and ensure staff adhere to standardized processes, and also facilitate communication and collaboration among health professionals. For improving medication packaging and labeling, the pharmacy department can provide valuable support and insights in creating standardized medication administration protocols, ensuring proper labeling and appropriate order formats. Besides, the department can play a role in evaluating medication-related errors and suggesting improvement strategies. These improvement plans also require the input of risk managers and patient safety officers who can provide expertise in determining and mitigating risks associated with patient safety. They can provide guidance on risk assessment, root cause analysis, reporting and analysis of adverse events, and strategy implementation to prevent medication administration errors. Utilizing existing resources in the facility reduces the likelihood of this safety issue and the costs related to such medical administration errors.
Conclusion
In healthcare systems, medication administration errors can occur at different points, such as prescribing, dispensing, administering, and communication. These errors have severe consequences for patient safety and require healthcare organizations to adopt evidence-based strategies to improve medication safety. A root cause analysis of medication administration errors was carried out on a patient admitted to the emergency department after being struck by a car. Human factors such as failure to verify correct medication and distractions majorly contributed to the medical administration error. Various evidence-based strategies like improved communication and collaboration during medication administration and fostering a culture of safety could help reduce such errors. Furthermore, an implementation plan was developed and focused on the need for a standardized medication administration process and improving medication packaging and labeling in the health care facility. Implementing this improvement plan, incorporating evidence-based strategies, and leveraging existing organizational resources can maximize the effectiveness of medication administration, hence achieving patient safety.
References
Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal of Nursing Care Quality, 35(4), E58–E62. https://doi.org/10.1097/NCQ.0000000000000473
Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis translates into improved patient safety: A systematic review. Medical Principles and Practice: International Journal of the Kuwait University, Health Science Centre, 29(6), 524–531. https://doi.org/10.1159/000508677
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046
Simas da Rocha, B., Garcia Moraes, C., Miyake Okumura, L., da Cruz, F., Sirtori, L., & da Silva Pons, E. (2021). Interventions to reduce problems related to the readability and comprehensibility of drug packages and labels: A systematic review. Journal of Patient Safety, 17(8), e1494–e1506. https://doi.org/10.1097/PTS.0000000000000619
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