NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper
Medication Errors Root Cause Analysis and Safety Improvement Plan Example Approach
Root cause analysis (RCA) is a tool used to investigate and understand the underlying causes of patient safety incidents, such as medication errors (Ahmed et al., 2019). It helps in problem identification so that health practitioners can introduce changes that improve care quality and patient experience. Medication errors are a typical incident that requires an RCA that will ultimately produce various recommendations to reduce medication errors and improve patient safety. The application of RCA to medication errors within a clinical care setting is critical considering the alarming numbers of increased length of stay, hospital injuries and death that adverse events have caused in American hospitals (Gates et al., 2019). For instance, according to Mazer and Nabhan (2019), at least 200,000 deaths are attributable to medication errors yearly, indicating that various root cause factors play a role in those events and are worth exploring. This report covers an RCA of ten hospitals in the US, analyzing and describing the fundamental causes and major contributors to medication errors, as well as an evidence-based plan and resources for improving patient safety.
Root Causes Of Medication Errors And Evidence-Based Solutions
When nurses, pharmacists, or physicians offer any type of healthcare service to patients, they can unknowingly inflict injury on the patient or cause adverse events such as medication errors or misdiagnosis. As per Gates et al. (2019), 10-20% of medication orders contain medication errors depending on the adverse event, for instance, delayed medicine administration. However, Gates et al. (2019) also found out that serious medication errors make up 5% of medication administrations in the US. In the case of Delaware Community Clinic, the management reports collected over the past 30 days indicated that for every 100 medication administration cases, seven errors are experienced. This number is above the acceptable rate of medication errors.
The data was collected through direct and non-participant medication preparation and delivery observations. The non-participatory observation of medication errors yielded important information about medication errors. For example, it was observed that distractions and secondary events were among the direct causes of medication errors in the Delaware Community Clinic. While most medication errors are preventable, they cause an array of adverse events, such as triggering new health conditions, patient injury, or, in the worst cases, death (Ibrahim et al., 2020). Medication errors also lengthen hospital stay, increases the cost of healthcare, and inflicts psychological or physical pain on the patient and their families. Medication errors in healthcare organizations reduce patient satisfaction and ultimately contribute to trust issues among nurses, physicians, and entire health organizations.
The RCA was conducted by a team of six practitioners, including a clinician, a supervisor, two quality improvement personnel and two nurses. The medication errors were recorded through nurse observations, emphasizing medication ordering and administration services. The error cases were categorized under prescription omission, wrong timing, improper usage, dose preparation and dosage, medication administration errors including extra dosage, and giving the wrong patient.
The observed incidences revealed that time, unauthorized administration, and dosage errors were the most prevalent, accounting for 17, 10 and 18 percent of the medication errors, respectively. The observations also indicated that the errors occur during periods of high activity, for instance, during shift changes and emergency calls. The RCA also showed that staff-related causes of medication errors were attributable to inadequate pharmacological knowledge. For instance, it was observed that nurses who lacked the ideal knowledge of the ideal medication administration route were likely to cause incidences of intravenous injections. The errors were also observed to be highly associated with poor knowledge of drug pharmacological properties as well as excessive dosage. These errors were observed to be primarily caused by the complex nature of intravenous medication, which requires vast experience to deliver the drug as optimally as possible.
Notably, the nurses who made these mistakes showed a lack of in-service training among newer staff, which constrained them of the necessary knowledge to prepare and deliver the drugs. As Mazer and Nablan (2019) recommended, in-service training on pharmacology and administration of complex medicine could be an excellent approach to reducing such medication errors.
The second root cause of medication errors in the Delaware Community Clinic was a shortage of nurses, which increased the workload of nurses needed at one point in time. Interviewed nurses revealed that medication errors were highly attributable to understaffing because nurses were pressured to cover the workload. Therefore, some evidence-based solution to understaffing is employing more nurses, ensuring a smoother change of shifts, and supporting the nursing staff as much as possible (Mazer & Nabhan, 2019). For instance, during the root cause analysis, it was observed that some laboratory staff could call the physicians to collect the lab results physically. However, the results could easily be transmitted to the physician using an electronic medical records system (EMRs). Rezaei (2019) recommends that EMRs can reduce medication errors by facilitating fast, efficient, and reliable transmission of patient information between nurses, pharmacists, laboratory technicians and the patient. Using technology to transmit necessary information, such as lab reports, could help minimize the pressure that comes with physically handling the data.
Improvement Plan
The improvement plan following this RCA will take two approaches: improving staff’s skills and knowledge and making the necessary environmental changes to minimize medication errors. The first item of the plan is to improve the hospital’s medication monitoring system to improve staff coordination and enhance prescription accuracy through various cross-checking points and communication among staff. The second improvement plan will be to train the staff to prevent medication errors, especially when administering complex medications such as intravenous injections. The training should improve the nurses’ pharmacological knowledge, especially on new drugs, contraindications, dosages, and proper administration.
Conclusion
Medication errors are associated with lengthened hospital stays, injury, increased care costs and even death. An RCA of the factors contributing to medication errors revealed important information on some of the leading causes and their potential solutions. The report indicated that nurses’ lack of skills and knowledge, followed by poor communication and distractions, are the most common cause of medication errors. Some of the evidence-based strategies for addressing the problem include the improvement of staff skills and knowledge and making the necessary environmental changes to minimize medication errors. These two solutions will provide a ground approach to minimizing medication errors in Delaware Community Hospital.
References
Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14. https://doi.org/10.1371/journal.pone.0217023
Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardizing the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931–939. https://doi.org/10.1007/s40264-019-00823-4
Ibrahim, O.M., Ibrahim, R.M., Meslamani, A.Z.A., & Mazrouei, N.A. (2020). Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes. Pharmacy Practice (Granada), 18(4), 2111. https://doi.org/10.18549/PharmPract.2020.4.2111
Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267. https://doi.org/10.1007/s11606-019-05156-7