Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN

Root-Cause Analysis and Safety Improvement Plan

RUTHANN BLIDGEN

NURS-FPX4020

Capella University

March, 2021

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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN

Root-Cause Analysis

Root cause analysis (RCA) is the process of discovering the "why" of problems in order

to identify appropriate solutions; RCA practitioners assume that it is far more effective to

consistently prevent and resolve underlying problems rather than just treating circumstantial

symptoms (Peerally et al., 2017). Carrying out this analysis implies having a series of principles,

techniques and methodologies that can be used to identify the original problem of an event or

trend (Singh, 2018). By looking beyond superficial effects of a phenomenon, RCA can show

where processes or systems failed or caused a problem in the first place.

Adverse events related to medications can lead to significant deterioration in the health of

patients, with significant economic and social repercussions. Medications are intended, among

others, to treat infectious diseases, prevent chronic diseases, and relieve pain (Khalil & Lee,

2018). In spite of this situation, improper administration of medications can also cause unwanted

reactions or even death. World Health Organization (2016) informed that medication errors (ME)

constitute a significant part of hospital casualties. There are multiple places where medication

errors can occur and will eventually compromise the patient's health: in the hospital, at the

healthcare provider's office, at the pharmacy, or at home. To counter these effects, preventive

measures have been established and proven to be useful (Alteren et al., 2018).

The purpose of this paper is to conduct a root-cause analysis on the subject of medication

errors caused (ME) during medical administration (MA) in the oncology unit of a health facility.

In addition, this paper will offer a plan to improve the safety of patients related to the concern of

medication administration safety based on the results of this analysis, with the help of literature

and professional best practices as well as the existing resources at your chosen health care setting

to provide a rationale for this plan.

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Analysis of the Root Cause

Patients receive the appropriate medication for their clinical needs, in doses

corresponding to their individual requirements, for an adequate period of time and at the lowest

possible cost to themselves and to the community. However, when it comes to hospital

emergency services, they are organized to offer rapid and complex care to patients with serious

pathologies, which makes them areas of high risk of errors. For this case, there was continuous

observation and documentation of the activity of three ED trained nurses, in the oncology unit,

when administering medication during a 12-hour shift from 5:30pm to 5:30 am. Each time one of

them was required to give medications to patients constituted an opportunity for error as well the

number of times administrations were inaccurate, delayed or omitted; the cumulative number of

times after the shift was over would increase the ME margin during MA.

Likewise, the observation also noted (but not counted) potential errors, or circumstances

capable of causing error, while it excluded the number of times the patients experienced adverse

drug reactions. Other variables collected were: 1) age of the patient; 2) type of drug involved in

the error. In addition, from which the following were selected: wrong drug administration,

omission in administration, incorrect dose, incorrect administration frequency, preparation error,

wrong administration technique, wrong route of administration, wrong speed of administration

and wrong patient.

One single observer, carried out this activity, alternating the areas to be observed as well

as the nurses; the observer was trained to intervene in the case of detecting any risk. The latter

involved consulting the electronic medical prescription and the guidelines of the center, and

compared them with the administration carried out, to verify their adequacy. The information

collected did not use any identifying data of any of the patients.

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By the time these observations took place there were a total of 16 patients in the oncology

unit; all of them were receiving medication. In the span of twelve hours, there was a total of 24

errors. 16 patients with a mean age of 70 years were included. 25% of the included patients

presented at least one medication error. More than half of the errors occurred in the first four

hours of the shift; all of them restricted to the oncology unit and its patients. Of the four nurses,

only one of them did not commit any medication errors during the shift. The most common

errors were: incorrect drug choice -unadministered- (8), wrong patient (6), omission in

administration (4), incorrect administration frequency (3), incorrect dose (2), wrong

administration technique (1). All of these events were prevented by the observer, meaning that

none of the patient’s actually received the incorrect medication and the error was prevented.

A common factor in all the errors was due to the fact that the nurses who made them did

not pass the medication through the label mechanism or omitted to consult the patient's chart

before administering the medication. Of the nurses monitored, all reported feeling accumulated

exhaustion, stress or fatigue, as well as personal problems. It was preponderant that all of them

expressed serious concerns of being infected by COVID-19 (although, in the unit, the patients

who present this type of cases are in another area).

During the monitoring, the nurses were asked if there were elements of the environment

that influenced their distraction or commit errors when administering medications, for example,

noise, oversaturation of information, altercations between colleagues or with patients, improper

use of mobile devices, or some other similar; none of them reported affirmatively that there was

influence of said events. When asking the nurses if they had any suggestions regarding the

implementation of a mechanism to reduce the occurrence of these errors, none of them made any

statements in this regard.

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Application of Evidence-Based Strategies

Literature suggests that, obtaining a broad view of the medication system allows

professionals the conditions of analysis and interventions that guarantee responsible and safe

care for patients and themselves (Neuss et al., 2016). The latter considering that, MA is

exacerbated in the case of nursing, especially when the patient is cared for in units with non-

specialized personnel (Mieiro et al., 2019). It is difficult to accept that a patient receives

treatment in a non-specialized unit, or in a specialized one by personnel without sufficient

experience.

On the other hand, several studies have repeatedly suggested establishing a rigorous work

system by carefully defining procedures and responsibilities within the unit (Looper et al., 2016;

Neuss et al.,2016). Finally, taking into account the stress and exhaustion factor, the volume and

rhythm of work of the nursing staff should be such that it can be adjusted to the established work

procedure; it is not acceptable to apply safety measures only to the extent permitted by the

working pressure (Tawfik et al., 2018).

Improvement Plan with Evidence-Based and Best-Practice Strategies

Elaborating an easy-to-read MA brochure or any type of informative document for the

nursing staff, containing relevant information that helps to prevent ME, following the procedures

approved in the Institution as well as the correspondent regulations. Added to the medical

prescription guidelines, it is important to emphasize on nursing professionals to make sure that:

The patient is correct, the information available (corresponding to the data available in the

Nursing Records or in the Clinical History and the prescription. In case of doubt about any

aspect related to the prescription, it is necessary to consult the corresponding protocol that

supports these practices (Karttunen et al., 2020).

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Existing Organizational Resources

Some of the existing organizational personnel and/or resources that would help improve

the implementation or outcomes of the plan, include the possibility of forming an

interdisciplinary team to elaborate the guidelines. Likewise, a series of lectures or roundtables

explaining these contents can help nurses to understand guidelines better. The more educated the

nursing staff is, the better it can perform their tasks.

Conclusion

Errors can result in serious problems for the patient and their family, such as generating

disabilities, prolonging the time of hospitalization and recovery, exposure to more procedures

and measures, delay or inability to resume their social functions, and even death. The

administration of medications can be considered, in a health institution, as the activity with the

highest risk, since they are inherent to the daily practice of patient care and because this activity

is closely linked and dependent on human action.

Medication errors in chemotherapy can have serious consequences for patients due to the

narrow therapeutic window of chemotherapy medications. In fact, the therapeutic dose is often

dictated by the limit of toxicity acceptable to the patient, so even small increases in dose can

have serious toxic consequences. Since medicating patients depends on merely human actions

and errors are part of that nature, however, a well-structured medication policy should promote

conditions that assist in the minimization and prevention of errors, implementing norms, rules,

actions, processes with the purpose of assist the professionals involved.

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References

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Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., ... &

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https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf