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NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Student Name

Capella University

NURS4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement

This report delves into a significant medication administration error at Tampa General Hospital (TGH), a prevalent issue that critically impacts patient safety. As a backdrop, medication errors rank as a leading cause of preventable harm in healthcare settings. Through this assessment, we will systematically explore the root causes behind such errors at TGH using Root-Cause Analysis (RCA). Subsequently, we will propose best practice strategies to mitigate these challenges, devise an evidence-based safety improvement plan, and identify organizational resources to bolster this plan’s success.

Analysis of the Root Cause

 Several medication administration errors occurred at Tampa General Hospital, but the incident with a 45-year-old patient, Hannah, instigated the use of RCA. Hannah underwent appendix surgery and was admitted for her post-surgery recovery. In one of the nurses’ rounds for medication administration, Hannah was administered the wrong medication by nurse Olivia. Hannah’s doctor had prescribed her morphine, ciprofloxacin, and heparin. The nurse examined her prescribed medications and went to the dispensing unit. Meanwhile, she received a phone call and started talking casually while dispensing medication from the automated dispensing system (ADS).

The ADS system faced glitches and dispensed the wrong medicines. Olivia was momentarily distracted by a phone call and paid no attention to the dispensed drug. She administered a double dose of heparin instead of morphine. This resulted in massive bleeding in the patient. This problem was detected by the nurse, Olivia, as she saw her patient bleed significantly. She immediately reported to an emergency, and Hannah’s bleeding was controlled.

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

This adverse event affected Hannah, her family, the organization, and the nursing staff. The patient’s recovery period was extended, and she had to undergo further procedures to control her bleeding. Moreover, her healthcare expenditures increased, and family members were distressed seeing her endure pain all over again. Healthcare organizations faced problems as their healthcare costs were further ameliorated due to additional treatments. The nursing staff was struck with fear and sadness as their poor attention toward patient care led to significant incidents, posing safety risks to patients’ lives. The root causes identified in this particular scenario were as follows:

  • Wrong Medication: The nurse administered the wrong medication, heparin instead of morphine, without double-checking or reading the label attentively before administration to the patient.
  • Non-Serious Attitude: The nurse exhibited a non-serious attitude and took phone calls while performing her duty and dealing with the patient’s life.
  • Non-Adherence to Medication Administration Protocols: The nurse did not implement the medication administration protocols, such as double-checking before administration, following the five rights of medication administration, and reading the medication label correctly.
  • Poorly Maintained Equipment: The automated dispensing system dispensed the wrong medication, and the healthcare organization did not pay attention to its adequate maintenance.

The RCA revealed these underlying causes, which contributed to the onset of the unfortunate adverse event. Considering these root causes, medication errors in the future can be prevented. Moreover, patient safety can be enhanced by implementing strategies that solve the above-mentioned issues.

Application of Evidence-Based Practice Strategies

 After conducting a thorough root-cause analysis, it is crucial to implement evidence-based strategies considering the underlying causes of medication administration errors at TGH. These evidence-based strategies can improve patient safety and reduce medication errors. Moreover, they will reduce the costs incurred by patients and healthcare organizations. One study shows that about 62.1 % of nurses make medication errors due to a lack of training on safe and effective medication administration (Wondmieneh et al., 2020).

Another study finds that external interruptions during medication administration, such as bedside conversations and taking phone calls, account for 18.8 % of medication errors (Manias et al., 2021). Another study highlights how healthcare information technologies also lead to medication administration errors due to poor maintenance and flaws in designing the technology to mitigate human errors (Ambwani et al., 2019). 

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

The best practices include training nurses on safe medication administration, where nurses can be educated on protocols regarding medication administration. Nurse leaders can play a vital role in training young nurses on the five rights of medication administration and how this strategy can address medication safety issues. As the five rights of medication administration include the right patient, the right drug, the correct dose, the right time, and the right route of administration, nurses can prevent medication administration errors due to the wrong medicine and the wrong patient (Manias et al., 2021).

Moreover, healthcare organizations can integrate a new technology of medication administration, i.e., Bar Code Medication Administration. This will enable double-checking with accuracy through barcode scanning of the label on the drug and matching it with the barcode mentioned on the patient’s bedside or wrist. This will ensure the patient is acquiring the medication prescribed to him with the help of Barcode (Owens et al., 2020).

Healthcare organizations can revise policies for nursing staff to carefully provide care treatments to patients and avoid external interruptions such as bedside communications, distracting conversations, and taking unnecessary phone calls. Any violation of these policies should instigate disciplinary actions and penalties. This will enhance a culture of careful administration of drugs without external interruptions (Yang et al., 2022).

 Evidence-Based Safety Improvement Plan 

Considering the alarming situation of TGH, where medication administration errors impact patients’ safety, developing a safety improvement plan for safe medication administration is imperative. This improvement plan accounts for the factors contributing to patient safety risks and can potentially lessen medication administration error rates. The plan consists of establishing training and educational sessions for nurses that guide nurses on safe medication administration.

Nurses will learn about medication administration techniques, protocols, and interdisciplinary collaboration to promote a safe medication administration culture (Manias et al., 2021). Moreover, the hospital will revise its standard SOPs for nurses, who must abide by the stringent policies on mindful medication administration. The guidelines will include penalties for inappropriate bedside communication during medication administration and no cellphone use during working hours (Yang et al., 2022). Lastly, the plan provides for integrating BCMA technology into safe medication administration (Owens et al., 2020). 

Desired Goals of Actions

  • Through adequate knowledge and education about medication, nurses will encounter the slightest chance of medication error, as they will be familiar with drug administration technology and implementation of the five rights of medicine.
  • The strict policies will eliminate external factors such as interruptions and phone calls, which may cause medication errors.
  • BCMA technology will prevent medication errors due to wrong medication, and patients will acquire the proper medication. This will enhance patient safety and reduce patient harm.

Timeline of Development and Implementation of Plan

The safety improvement plan will be developed in two months, requiring resource estimation and budget management. Moreover, the practical implementation will be executed within three months after development. For instance, the plan will be implemented on a small scale in one hospital department. After three months of implementation and evaluation, revision of the program will be done, and it will be implemented in all departments of the hospitals.

Existing Organizational Resources

The hospital will require human and financial resources to implement a safety improvement plan. The prioritized human resources will include hospital administration, nurse leaders, IT specialists, physicians, and pharmacists. The healthcare administration will be involved in policy-making for safe medication administration, such as no phone use during working hours and penalties for violating rules. The nurse leaders will conduct training and educational programs for nurses to enhance their knowledge of medication administration. Additionally, the existing training modules could improve training sessions with further revisions for improvements.

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Moreover, the existing automated dispensing system can be maintained properly to reduce future glitches.  The IT specialists will participate in integrating BCMA technology and guide other healthcare providers on its practical use. The physicians will play their role in safe prescribing to overcome prescription errors. On the other hand, pharmacists will collaborate with nurses on accurately dispensing drugs. The financial costs will be required for training sessions such as educational materials use of computers. Moreover, the integration and operational costs of BCMA technology will be essential for successfully implementing this technology. These resources will collectively result in the successful and effective implementation of the safety improvement plan.

Conclusion

This paper utilizes root-cause analysis methodology to solve medication administration issues at Tampa General Hospital. The root causes of medication administration incidents were nurses’ lack of mindful and attentive behaviors, wrong medication administration, and poor maintenance of ADS technology. Considering these root causes, evidence-based strategies were applied to address the issues.

The design comprised nurses’ education on safe medication administration, BCMA implementation, and hospital policy revision. The safety improvement plan involved the implementation of these strategies within a time frame of three months on a small scale. Lastly, existing organizational resources include human and financial resources to implement the recommended safety improvement plan successfully. 

References

Ambwani, S., Misra, A., & Kumar, R. (2019). Medication errors: Is it the hidden part of the submerged iceberg in our health-care system? International Journal of Applied and Basic Medical Research, 9(3), 135. https://doi.org/10.4103/ijabmr.ijabmr_96_19 

Hodkinson, A., Tyler, N., Ashcroft, D. M., Keers, R. N., Khan, K., Phipps, D., Abuzour, A., Bower, P., Avery, A., Campbell, S., & Panagioti, M. (2020). Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Medicine, 18(1). https://doi.org/10.1186/s12916-020-01774-9

Manias, E., Street, M., Lowe, G., Low, J. K., Gray, K., & Botti, M. (2021). Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: A retrospective clinical audit. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07033-8 

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing, 46(6), 884–891. https://doi.org/10.1016/j.jen.2020.07.004

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0

Yang, R., Gu, Q., Chen, F., Yang, Y., Gu, L., Zhang, J., Lu, Z., & Zhang, X. (2022). Effect of evidence-based nursing management of protocol compliance in anticancer drug clinical trial. Asia-Pacific Journal of Oncology Nursing, 9(10), 100114. https://doi.org/10.1016/j.apjon.2022.100114