NURS4020 Root-Cause Analysis and Safety Improvement Plan Essay

NURS4020 Root-Cause Analysis and Safety Improvement Plan Essay

NURS4020 Root-Cause Analysis and Safety Improvement Plan Essay

Improving Quality of Care and Patient Safety

Patient safety during medication administration is important as it prevents the occurrence of medication errors. Medication errors are sentinel events that impact quality of care and emanate from different causes as highlighted in the previous paper. These include failure to implement safety measures like use of five rights of medication administration, ineffective and inappropriate communication as well as workplace culture and environment (Umberfield et al., 2020). The purpose of this paper is to conduct a root-cause analysis of medication errors emanating from failure to implement safety measures in the organization and propose a safety improvement plan. The paper uses a root-cause analysis (RCA) model to evaluate and provide evidence-based practice solution by creating a safety improvement plan and identification of current organizational resources to enhance the proposed plan.

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Analysis of the Root Cause

Patient safety and care are the main concerns for any effective healthcare delivery system. Studies show that close to 251,000 patients die as a result of medication errors during the medication administration process (Lukewich et al., 2019). Medication errors, especially during administration, predispose patients, their families, and clinicians to adverse outcomes like disabilities, losses, legal suits, and in unfortunate cases, death. The root cause analysis (RCA) model provides a framework to assess the causes of medication errors in healthcare facilities like critical care units. The RCA is a systematic process that identifies the causal factors that lead to the occurrence of medication errors. The Joint Commission (TJC) through its patient safety goals considers the RCA as a critical tool to increase efficiency through determining factors that lead to occurrence of unsafety events, including incivility in the nursing practice setting.

As stated, ineffective and inappropriate communication among interdisciplinary team members involved in the medication administration process is the leading cause of medication-associated adverse events, especially errors. Confusion among medical profession arises when medications have similar names. Again, events like burnout, fatigue, and incivility in the workplace can predicate the occurrence of medication errors (Lukewich et al., 2019). Inappropriate communication like getting calls while administering medications or phone conversations that are disruptive can lead to medication errors because of limited concentration levels. Giving patients a medication prescription verbally may also lead to misunderstanding of the instructions when taking the medicines or create unnecessary confusion (Guttman et al., 2021). Again, based on the RCA model, poorly written diagnosis can lead to misunderstanding even among pharmacists and increase the possibility of mistakes in the healthcare settings. Medication errors also emanate where there is lack of clarity in communication concerning medicines, their names, and adverse effects (Salar et al., 2020). The lack of effective training for healthcare providers can also lead to medication errors. The implication is that the RCA shows the need for effective communication as the most appropriate way to deal with medication errors as sentinel events in healthcare.

Application of Evidence-Based Strategies

Existing evidence from literature suggests that certain factors have a direct effect leading to the occurrence of medication errors (Guttman et al., 2020). The determination of these factors is necessary to implement best practice strategies to address medication error. The Joint Commission’s Patient Safety Goals framework provides different practices that lead to safety for patients and providers. These goals offer evidence and direction to create a safer environment for healthcare organizations through effective communication (TJC, 2023). Communication failures and errors of omission are the most prevalent causes of medication errors (Guttman et al., 2021). Lack of information and lack of a shared understanding as well as goal can lead to communication breakdown. Imperatively, healthcare organizations and providers should improve communication channels and means among the staff to reduce medication errors emanating from insufficient information.

Best practices in reducing and preventing medication errors emanating from communication failures require providers and organizations developing interventions supported by existing evidence. These include avoidance of abbreviated prescriptions, use of computerized entry system like the computerized physician order entry (CPOE) and clinical decision support system (CDSS) to avoid human-related errors and mistakes. Furthermore, it is essential for stakeholders in the medication administration process to compare patients’ medication orders with other medications using the medication reconciliation model to avoid omission, and dosing as well as other associated errors and duplications (Poder & Maltais, 2020). The use of automated dispensing system and creation of a just culture among the healthcare providers are some of the evidence-based strategies to prevent the occurrence of medication errors. The just culture addresses the issue of individual causes of medication errors by ensuring that there are no retributions, punishments or reprimands for those who may make mistakes in the process.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan should focus on enhancing adherence to medication process, especially the five rights, providing sufficient education and awareness, changes in system design by leveraging technologies, and development of a just culture policy that encourages reporting of errors (Smith et al., 2019). Reporting of experienced errors in the medication process would encourage support and multidisciplinary cooperation and collaboration to improve overall environment setting. Education is vital as it will allow nurses and physicians as well as pharmacists to improve their communication, beginning with the writing of the prescription (Martyn et al., 2019). Leveraging technologies will lead to having an automated dispensing system which entail the use of CPOE and CDSS to improve adherence and even implementation of the situation, background, assessment and recommendation (SBAR) model. The SBAR model is an effective framework, especially during shift handover, for nurses and other providers to improve their level of communication. Again, approproiate labeling and naming of medicines would also help reduce medication errors.

The goal of this plan is to improve the efficiency of the medication administration process to reduce and prevent errors. The desired outcome is to reduce medication errors by 50% within the next two months in the facility. This proposed project will require six months of implementation and analysis of the associated results to make new recommendations aimed at entrenching a safety culture in the organization.

Existing Organizational Resources

The successful implementation of this plan will leverage the existing organizational financial and human resources. For example, instead of investing in additional personnel like external trainers who need payment, the organization can offer sufficient training to its nurses and nurse leaders to leverage their current skills and knowledge to implement these changes. The nurses can attain training in practical areas like ways to differentiate medications and use technologies like CPOE. Secondly, the organization should leverage its current technologies and only acquire those devices and software that it does not have to reduce medication errors (Martyn et al., 2019). These guidelines and policy issues require only training and leveraging technologies within the working framework and space of the current nursing workforce in the organization. Therefore, the present resources are sufficient and will only need to invest in improving the current technologies at reasonable cost.

Conclusion

Medication errors are among leading causes of patient’s adverse events and experiences, including deaths and increased cost of care. Healthcare providers and organizations should leverage evidence-based approaches and technologies to help reduce and prevent the occurrence of these errors. Effective communication ensures that all stakeholders understand their various responsibilities and duties to deal with these errors as sentinel events in care delivery.

References

Guttman, O. T., Lazzara, E. H., Keebler, J. R., Webster, K. L., Gisick, L. M., & Baker, A. L.

(2021). Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Journal of patient safety, 17(8), e1465-e1471. DOI: 10.1097/PTS.0000000000000541.

Lukewich, J. A., Tranmer, J. E., Kirkland, M. C., & Walsh, A. J. (2019). Exploring the utility of

the nursing role effectiveness model in evaluating nursing contributions in primary health

care: A scoping review. Nursing Open,6(3), 685-697.

DOI: http://dx.doi.org.library.capella.edu/10.1002/nop2.281

Martyn, J. A, Paliadelis, P., & Perry, C. (2019). The safe administration of medication:

Nursing behaviors beyond the five-rights. Nurse Education in Practice, 37, 109-114.

DOI:http://dx.doi.org.library.capella.edu/10.1016/j.nepr.2019.05.006

Poder, T. G., & Maltais, S. (2020). Systemic analysis of medication administration omission

errors in a tertiary-care hospital in Quebec. Health Information Management Journal, 49(2-3), 99-107. DOI: 10.1177/1833358318781099

Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, barriers and potential strength of

nursing in implementing evidence-based practice. International Journal of Caring Sciences, 13(2), 1203–1211. http://www.internationaljournalofcaringsciences.org/docs/44_1_rahmayanti_original_13_2.pdf

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A

qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235

Smith, A. F., & Plunkett, E. (2019). People, systems and safety: resilience and excellence in

healthcare practice. Anesthesia, 74(4), 508-517. DOI: 10.1111/anae.14519.

The Joint Commission (TJC) (2023). National Patient Safety Goals Effective January 2023 for

the Hospital Program. https://www.jointcommission.org/ /media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf

Umberfield, E., Ghaferi, A. A., Krein, S. L., & Manojlovich, M. (2019). Using incident reports

to assess communication failures and patient outcomes. The Joint Commission Journal on Quality and Patient Safety, 45(6), 406-413. DOI: 10.1016/j.jcjq.2019.02.006.

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Quality and Safety
• Ambutas, S., Lamb, K. V., & Quigley, P. (2017). Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units. Medsurg Nursing, 26(3), 175–179, 197.
o The implementation of a safety improvement project is examined in this article.
• Institute for Healthcare Improvement. (n.d.). Why is reducing harm – not just error – important to patient safety? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/Bates-Reducing-Harm-Important-To-Patient-Safety.aspx
o Based on the premise that human error may be reduced but not avoided in every health care situation, this video focuses on the importance of harm reduction to patient safety.
• The Joint Commission. (2018). 2018 national patient safety goals. https://www.jointcommission.org/standards_information/npsgs.aspx
o The patient safety resources on this Web page may be helpful as you develop the improvement plan section of your assessment.
• Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636–639.
o This article summarizes the creation of a safety program to reduce sentinel events.
• U.S. Department of Health & Human Services. (n.d.). https://www.hhs.gov/
o Explore numerous resources related to quality and safety on this website as you develop your assessment submission.