Root-Cause Analysis and Safety Improvement Plan

Learner’s Name

Capella University

NURS-FPX4020

Root-Cause Analysis and Safety Improvement Plan

September 2021
 Medication Errors: Introduction

Medical errors can lead to death in the worst-case situation. There are a variety of

pharmaceutical mistakes that can occur during the prescription procedure, according to

Rishoej and colleagues (2017, p.1697). To quote from The Joint Commission International

(2015), a root cause is a failure or circumstance in which expectations are not met. I'm going

to talk about Josie's death in a hospital due to drug abuse.

Event

Children's Hospital at John Hopkins in 2001 treated Josie King when she was 18

months old. First and second-degree burns were sustained by the kid when he entered the

hot bathwater. After 10 days in the pediatric intensive care unit, it was decided that Josie

would be released from the hospital. It was Mother Sorrel's concern about Josie's thirst that

prompted the removal of her daughter's central line. Lavishly sucking water from a

washcloth, the nurse observed that the 18-month-old was thirsty while being washed. It was

reported by another nurse that Sorrel's vital signs were within normal norms, disregarding

Sorrel and telling her mother that this was typical. Sorrel wanted to visit the doctor when he

got back to the hospital since Josie didn't appear to be doing well at all. Doctors gave Narcan

to Josie twice before she was allowed to drink. Following his instruction, no medications

would be supplied. Sorrel takes up her daughter's nurse's behavior with the doctor since she

has concerns about it as well. The doctor finally agreed. As a result of the nurse bringing in

the methadone syringe, Josie's mother became concerned. 'No narcotics will be distributed,'

stated Sorrel. As a result of this modification of the orders, she was able to give the

medication. She was readmitted to the PICU after receiving the incorrect medicine.
 Analysis of the Root Cause

Medication errors are more common in children since their dosage is dependent on

their weight and surface area, as opposed to adults (Rishoej et al., 2017, p. 1697). Pediatric

inpatients suffer from MEs and adverse medication responses at a rate of 2.3 to 6%,

according to research (Rishoj et al., 2017, p. 1697).

As a patient advocate, Josie's nurse should have communicated Sorrel's worry that

her daughter was showing indications of thirst. As a result, she might have checked if the

order for no fluids was still in effect if she had phoned the doctor. The nurse didn't tell Josie

to drink more water, but she didn't check to see whether Sorrel's fear about the narcotic

was true. Sorrel didn't realize she could refuse Josie's methadone since she didn't know her

rights as a patient.

The nurse may have made a mistake because she was overworked. That day, how

many nurses worked? Is the nurse-to-patient ratio adequate in this case? There must have

been a reason why the nurse did not contact the doctor both times. A new nurse should

have taken care of Josie, given the mother's dissatisfaction with the former. Sorrel's various

complaints should have been addressed by the other staff members who listened to him.

Was the doctor's verbal instruction to Josie that no drugs be administered to her

recorded in her medical record? Patient care can be improved when orders are given

verbally. If a doctor enters orders for a patient, there will be no delays or confusion. All

those concerned in Josie's care were unable to communicate effectively. Sorrel, who did not

realize she had the authority to reject methadone administration as Josie's mother, also had

a role in her daughter's death.

Improvement Plan with Evidence-Based and Best-Practice Strategies

contribute to MEs. It is less well known that HALT (hunger, anger, loneliness, and tiredness)

are contributing causes of mistakes (Rague et al., 2018). Mistakes about human error have

been decreased by 25%, while those connected to documentation or communication errors

have been reduced by 22% as a result of the HALT approach (Rague et al., 2018). This can

involve taking 5 minutes off the floor to take deep breaths, reallocating nursing duties to

remove any RN suffering HALT, or restructuring patient workloads to enable timely breaks,

among other things (Rague et al., 2018). It helps a nurse to take care of oneself by looking at

a possible detrimental influence on their attitude and well-being before they offer patient

care by utilizing the HALT paradigm.

MedsIQ is made up of two components: tools and improvement initiatives that have

been developed to target specific problems that harm children through pediatric

pharmaceutical mistakes (Cass, 2016, pp. 415-416). The second component, Paediatric Care

Online UK, includes clinical decision support tools and other essential materials in a style

that can be cross-linked to quality assured-practice advice (Cass, 2016, pp. 415-416).

Use daily medication timeouts during rounds as a short, affordable, and rapid

improvement strategy with the potential to affect patient safety (Tainter et al., 2018, p.

367). Each time a pharmacist or other member of the team visits a patient during rounds,

they would check the electronic medical record to see whether there were any new drugs

prescribed (Tainter et al., 2018, p. 367). There was an average of 1.6 drug changes per

patient, according to a study by Tainter et al. (2018). Medication administration is governed

by five rights, which nurses are taught in school. When nurses use evidence-based practice
before and during administration, they are more likely to identify a mistake before it leads

to harmful side effects.

Improvement Plan

Improving the knowledge and abilities of employees and modifying the environment

to minimize medication mistakes will be the emphasis of the improvement plan. As part of

the strategy, the drug monitoring system will be improved, from the moment of ordering

through the point of administering (Polnariev, 2016). Personnel improvements, cross-

checking, and prescription accuracy confirmation will be the emphasis of future

developments. Staff communication will also be improved. A nurse should be able to ask a

physician or other player about the correctness of an order using the hospital's information

system's drug ordering component, for example. There are times when a nurse should

double-check a medication's prescription information with both the prescribing physician

and their electronic medical record (EMR) to make sure it is accurate and acceptable

(Polnariev, 2016). There must be a high level of communication amongst all members of the

health care team engaged in prescriptions and drug administration for the measure to be

successful.

Nurses will be given the training they need to prevent medication errors as part of

the second aspect of the improvement plan. For starters, practitioners need to be trained in

basic areas like drug calculations, which are crucial for safe treatment and delivery. To

maintain nursing skills, the nursing leadership should have a three-month refresher training

program (Polnariev, 2016). While focusing on new medications, dosage, contraindications,

and correct administration during the training, the nurse must continue to develop her

pharmacological knowledge. Aside from patient monitoring, paperwork, and teaching, there
are several more aspects that should be covered in training to guarantee prescription

accuracy.

For maximum patient safety, the third goal is to eliminate environment- and context-

related causes of drug mistakes. Adopting the sterile cockpit rule principle, which eliminates

distractions during medicine preparation and administration, is one of the adjustments that

should be made to reduce the risk of adverse reactions. "Do not disturb" signs should be

placed at the medicine production location, and other practitioners should be informed that

they cannot request anything from those actively participating (Flynn et al., 2016). Patients,

drugs, dose, route, and time should all be checked during medicine preparation and

delivery, according to the five rights principle of medication (Sealock et al., 2021, p. 7). This

will allow nurses to identify and correct any mistakes that may have occurred when

ordering, prescribing, or any of the earlier phases of care. Lastly, nurses should educate

patients about drugs, including their effects, probable side effects, and intended results,

according to the American Nurses Association. Measuring efficacy guarantees that a

patient's response to a drug is optimal.

Conclusion

Injuries, hospitalizations, deaths, and higher healthcare expenditures are all linked to

medication mistakes. The root-cause analysis of medical mistakes at a major clinic gave vital

information on the primary causes and the probable remedies to implement for preventing

medical errors. Study results reveal nurse/physician distraction is the top cause of medical

mistakes, followed by inadequate knowledge/skills and ineffective communication amongst

professionals. Evidence-based solutions for dealing with this problem were examined in the

paper, which provided vital insights into the adjustments needed to address the number of
medication mistakes recorded in the last few months. Human and environmental factors

will be addressed as part of a two-pronged strategy to decrease prescription mistakes.

A hospital's ability to communicate effectively with patients is essential to providing

them with high-quality treatment. Patients and their families might suffer greatly as a result

of misunderstanding drug mistakes and medical prescriptions. Nonmaleficence is an ethical

concept that we must respect in our roles as healthcare providers.

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.

[Link]

Cass, H. (2016). Reducing pediatric medication error through quality improvement

networks; Where evidence meets pragmatism. Archives of Disease in Childhood,

101(5), 414–416. [Link]

Flynn, F., Evanish, J.Q., Fernald, J.M., Hutchinson, D.E., & Lefaiver, C. (2016). Progressive

Care Nurses Improving Patient Safety by Limiting Interruptions during Medication

Administration. Critical Care Nurse, 36(4), 19-35.

[Link]

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.

[Link]

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. Pharm Pract (Granada), 18(4), 2111.

[Link]

Ragau, S., Hitchcock, R., Craft, J., & Christensen, M. (2018). Using the HALT model in an

exploratory quality improvement initiative to reduce medication errors. British

Journal of Nursing, 27(22), 1330–1335.

[Link]
Rishoej, R. M., Almarsdóttir, A. B., Christesen, H. T., Hallas, J., & Kjeldsen, L. J. (2017).

Medication errors in pediatric inpatients: A study based on a national mandatory

reporting system. European Journal of Pediatrics, 176(12), 1697–1705.

[Link]

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective

Action of Sentinel and Adverse Events, 7th Edition | Joint Commission Resources.

(2020). Joint Commission Resources. [Link]

health-care-a-joint-commission-guide-to-analysis-and-corrective-action-of-sentinel-

and-adverse-events-7th-edition/

Tainter, C. R., Nguyen, A. P., Pollock, K. A., O’Brien, E. O., Lee, J., Schmidt, U., Jahanasouz, F.,

Owens, R. L., & Meier, A. (2018). The impact of a daily “medication time out” in the

Intensive Care Unit. Journal of Critical Care, 43, 366–369.

[Link]