Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Name

Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Improvement Plan

Root-cause analysis (RCA) is an approach that evolved in the medical field and is used to explore the direct and indirect contributing variables for a preventable adverse event and develop a prevention strategy (Kwok et al., 2020). The most common application of RCA in healthcare is in the analysis of Medication Administration Errors (MAEs), which contribute to Adverse Drug Events (ADE). ADE has adverse patient implications, ranging from insignificant negative outcomes to potentially fatal situations (Singh et al., 2023). MAEs resulted in a patient safety issue at the Vila Health Hospital. This study will investigate the root cause of the MAE incident, taking into account the factors that contributed to the problem. Furthermore, an evidence-based safety improvement plan will be developed based on the organization’s available resources to avoid such problems. 

Root-cause analysis of medication administration errors

One of the biggest causes of preventable patient damage in healthcare systems is inappropriate drug practices. The majority of these errors occur during the process of administration of drugs. Nurses are mainly accountable for MAEs (Wondmieneh et al., 2020). Lack of collaboration and records, a lack of medication interaction understanding, and inadequate instruction for patients result in MAEs that cause ADE (Guncag et al., 2021). By completing a comprehensive RCA, organizations can determine the sources of mistakes and design focused measures to avoid adverse events. A 52-year-old, Mr. Joseph, experienced adverse events due to MAEs. He was the patient of cardiac myopathy.

During his hospital stay, the nurse misunderstood his handwritten medication prescription and gave him the wrong medicine, resulting in severe ADE, including increased cardiac rate and shortness of breath. It happens due to the injurious reaction of the wrong medicine with other drugs. The medication administration mistake committed by the nurse was an underlying concern. Poor standard of care and uncertain practices can result in significant death and disability in patients (Vaismoradi et al., 2020). To prevent repeated occurrences of severe drug reactions due to MAEs, it is critical to develop compatible guidelines for medication dispensing and highlight the importance of administering drug education (Vaismoradi et al., 2020). As a result, it is critical to recognize the elements contributing to the issue and develop an immediate safety improvement plan to address them.

Elements Contributed to Safety Issues

Assessing the primary cause of the patient protection concern, mainly Ms. Joseph’s MAE incident indicates various contributing variables relating to drug administration in the healthcare system.

• Inappropriate Medication Reconciliation (MR) and evaluation methods, such as the absence of complete drug records and accurate prescription histories, result in MAEs and harm the well-being of patients (Millichamp & Johnston, 2020).
• During nursing training, nurses acquire the five rights of administering medicines, which include the proper patient, prescription medicines, dosage, mode of delivery, and time. However, there are instances where nurses fail to adhere to this standard guideline, resulting in MAEs (Martyn et al., 2019). According to research, 38.6% of pharmaceutical mistakes were attributed to incorrect time management, while 27.5% were attributed to incorrect evaluation and prescription to the incorrect patient (Tsegaye et al., 2020).

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

• The absence of defined standards for pharmaceutical prescribing, as well as clear recommendations and decision support systems, leads to dependence on human knowledge, which increases the risk of MAEs and adverse events (Alshahrani et al., 2021).
• Continuing professional education (CPD) is critical for nurses to promote and upgrade their expertise and abilities based on recent developments (Hakvoort et al., 2022). It is reported that improper or lack of training of nurses leads to the MAEs. According to research, 78.7% of MAEs are caused by inadequate education (Tsegaye et al., 2020). This evidence demonstrates that nurses with a limited understanding of medications can make mistakes during medication administration without identifying side effects that can compromise patient safety (Hakvoort et al., 2022).

Application of Evidence-Based Strategies

Evidence-based and standard interventions can tackle the incidents due to MAEs and the fundamental reasons indicated for these issues. The MR process is critical in encouraging an appropriate approach to drug administration. Hazardous occurrences can be decreased to promote patient safety through effective MR, minimizing unnecessary hospitalizations and lowering medical costs (Milanez-Azevedo et al., 2022). Integrating Electronic Health Records (EHR) systems with MR allows for the accessibility of correct and updated medication records. It assists in lowering healthcare administrative expenses by eliminating duplicate drug prescriptions or problems with duplication and related issues (Adane et al., 2019).

Introducing the Medication Error Reporting System (MERS) assists with recognizing possible contributors or indicators for medication mistakes. MERS provides beneficial data by revealing issues that need improvement to increase patient safety (Karande et al., 2021). Moreover, this system is critical for readily minimizing mistakes and their associated ADR. MERS allows doctors and nurses to assess causative variables in the incidence of prescription mistakes. This framework prevents medication-related adverse reactions (Afaya et al., 2021).

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Barcoding scanning or Barcoding Medication Administration (BCMA) system can aid in reducing ADE by improving medication administration. The BCMA approach promotes the accuracy and efficacy of drug distribution and administration. Scanning barcodes confirms the details of the medication, ensuring that the appropriate drug, dose, and procedure is employed. The BCMA program helps caregivers accurately assess patients to avoid MAEs. This method allows healthcare facilities to accomplish goals related to patient safety (Owens et al., 2020).

Collaboration and coordination with pharmacists and health personnel can also assist patients with complex health issues in analyzing pharmaceutical prescriptions. Raising drug interaction awareness and instruction is essential in reducing MAEs (Jaam et al., 2021). To reduce MAEs and their impact on patient safety, comprehensive training sessions for medical professionals concentrating on drug interactions and medication administration are required (Vifladt et al., 2023).

How Strategies Address Adverse Events Related to Medication Administration Error

Evidence-based techniques will deal with the ADE associated with MAEs. Medical personnel can obtain detailed drug details by integrating EHR and BCMA (Owens et al., 2020). MERS assists in the identification of potential causes or hazards for medication errors. Medication errors will be reduced by standardizing prescribing guidelines and collaborating with medical providers (Karande et al., 2021). Additionally, improved medication interaction awareness and training programs will increase medical care personnel understanding and minimize MAE event, enhancing patient safety by lowering ADE (Vifladt et al., 2023).

Evidence-Based Safety Improvement Plan

The safety improvement strategy intends to improve appropriate drugs dispensing techniques in order to avoid ADEs in the hospital. The plan includes evidence-based initiatives that promote the greatest degree of patient safety. The first step of the plan is delivering medical personnel educational opportunities and training, which will provide medical personnel with the expertise and skills needed (Lee & Quinn, 2019). Medication safety awareness and understanding are also promoted through extensive initiatives that motivate participation in ongoing learning activities. This educational intervention aims to provide nurses with the information, abilities, and mindsets needed to provide safe and high-quality patient care (Lee & Quinn, 2019).

In the second phase of plan technological measures to reduce mistakes in medication or drug administration and enhance effectiveness.   Owens et al. (2020) suggested that, Integrating BCMA with EHR systems, can lower the chance of severe health issues. In addition, the approach concentrates on establishing the medication administration processes through the use of Computerized Physician Order Entry (CPOE) systems in conjunction with decision support systems. CPOE can give details about pharmaceutical interactions to increase prescription reliability and prevent errors (Jungreithmayr et al., 2021).

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

The plan’s third phase concentrates on creating an environment of drug security reporting, education, and continual enhancement, encouraging the nurses and other medical professionals to report the events of MAEs if they occur. Hospitals can develop significant incident reporting systems by examining MAE instances and driving perpetual enhancement. It will help to identify the areas that need to be improved. Healthcare facilities can address drug delivery problems, promote patient safety, and develop an attitude of ongoing quality enhancement through the implementation of this evidence-based safety improvement plan (Afaya et al., 2021).

Existing Organizational Resources

Medical facilities must efficiently employ their existing resources to improve patient safety in drug delivery. Prioritizing current assets by considering their possible effect can help the organization considerably enhance drugs safety. The EHR system at the healthcare setting is an significant asset for enhancing medication safety and reducing MAEs. Medical personnel can access patients’ precise and updated perscription and other medical information by the EHR system (Adane et al., 2019). Furthermore, MERS gives vital information by indicating aspects that need advancement to foster patient safety (Afaya et al., 2021).

The knowledge of pharmacists and resources of the hospital’s pharmacy are critical to fostering medication safety. They are crucial to guiding nurses and other medical professionals about drug prescriptions and possible side effects (Fernandes et al., 2020). Pharmacists play an important role in implementing standardized pharmaceutical prescribing procedures that ensure accuracy and provide pharmaceutical knowledge and suggestions. Drug reconciliation by pharmacists aids in medication administration. Collaboration with pharmacy services can considerably improve safe medication practices and reduce the risk of ADE by overcoming MAEs (Fernandes et al., 2020).

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

 The organization can drive continuous improvement initiatives in drug safety by employing preexisting Quality Improvement (QI) groups (Tuti et al., 2022). QI experts can execute periodic inspections, review medical management information, and suggest opportunities for improvement. QI staff can effectively assist in improving medication administration procedures by employing evidence-based methods and interventions (Pereira et al., 2020). In addition, the medical education sections of the organization are critical in providing medical professionals with the necessary understanding and abilities needed for safe pharmaceutical administration (Vifladt et al., 2023). These groups can create extensive medication administration and safety teaching courses and sessions by advocating through evidence-based guidelines (Vifladt et al., 2023). 

 Nurses can coordinate with physicians and other healthcare professionals to guarantee that drug prescriptions are appropriate and to receive verification when necessary. The partnership among participants is critical for ensuring consistent and effective medication delivery practices (Marufu et al., 2022). The organization’s financial resources will be utilized to implement EHR and CPOE systems. These are the most effective organizational systems for preventing MAEs because they enable immediate access to extensive patient medication data (Jungreithmayr et al., 2021).

Conclusion 

Managing the root cause of MAE necessitates technology assistance as well as the expertise and abilities of healthcare personnel. In healthcare organizations, an extensive strategy for medication reconciliation is critical for enhancing pharmaceutical safety and lowering MAE-related adverse events. By utilizing current resources, organizations can improve drug administration procedures and build an environment of safety. Incorporating evidence-based approaches will reduce MAE potential hazards, improve patients’ quality of life, and ensure continued advancement in minimizing medication side effects.

References

Adane, K., Gizachew, M., & Kendie, S. (2019). The role of medical data in efficient patient care delivery: a review. Risk Management and Healthcare Policy, 67-73. https://doi.org/10.2147/RMHP.S179259

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. Bio Med Central Health Services Research, 21, 1-10. https://doi.org/10.1186/s12913-021-07187-5

Alshahrani, F., Marriott, J. F., & Cox, A. R. (2021). A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. International Journal of Clinical Pharmacy, 43, 884-892. https://doi.org/10.1007/s11096-020-01192-0

Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605-613. https://doi.org/10.1016/j.sapharm.2019.08.001

Guncag O., Bucknall, T., Woodward‐Kron, R., Hughes, C., Jorm, C., Joseph, K., & Manias, E. (2021). A systematic review of older patients’ experiences and perceptions of communication about managing medication across transitions of care. Research in Social and Administrative Pharmacy, 17(2), 273–291. https://doi.org/10.1016/j.sapharm.2020.03.023

Hakvoort, L., Dikken, J., Cramer-Kruit, J., Molendijk-van Nieuwenhuyzen, K., van der Schaaf, M., & Schuurmans, M. (2022). Factors that influence continuing professional development over a nursing career: A scoping review. Nurse Education in Practice, 103481. https://doi.org/10.1016/j.nepr.2022.103481

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Jaam, M., Naseralallah, L. M., Hussain, T. A., & Pawluk, S. A. (2021). Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. PloS One, 16(6), e0253588. https://doi.org/10.1371/journal.pone.0253588

Jungreithmayr, V., Meid, A. D., Haefeli, W. E., & Seidling, H. M. (2021). The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation—a before-and-after study. Bio Med Central Medical Informatics and Decision Making, 21, 1-12. https://doi.org/10.1186/s12911-021-01607-6

Karande, S., Marraro, G. A., & Spada, C. (2021). Minimizing medical errors to improve patient safety: An essential mission ahead. Journal of Postgraduate Medicine, 67(1), 1. https://doi.org/10.4103%2Fjpgm.JPGM_1376_20

Kwok, Y. T. A., Mah, A. P., & Pang, K. M. (2020). Our first review: An evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals. Bio Med Central Health Services Research, 20, 1-9. https://doi.org/10.1186/s12913-020-05356-6

Lee, S. E., & Quinn, B. L. (2019). Incorporating medication administration safety in undergraduate nursing education: A literature review. Nurse Education Today, 72, 77-83. https://doi.org/10.1016/j.nedt.2018.11.004

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. https://doi.org/10.1016/j.nepr.2019.05.006

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Marufu, T. C., Bower, R., Hendron, E., & Manning, J. C. (2022). Nursing interventions to reduce medication errors in paediatrics and neonates: Systematic review and meta-analysis. Journal of Pediatric Nursing, 62, e139-e147. https://doi.org/10.1016/j.pedn.2021.08.024

Milanez-Azevedo, M., Zago-Oliveira, T., Alves-Reis, D., Leira-Pereira, L. R., & Rossi-Varallo, F. (2022). Pharmacist-led medication reconciliation in emergency hospital services in Brazil: A scoping review. Farmacia Hospitalaria, 46(4), 234-243. https://doi.org/10.7399/fh.11838

Millichamp, T., & Johnston, A. N. (2020). Interventions to support safe medication administration by emergency department nurses: An integrative review. International Emergency Nursing, 49, 100811. https://doi.org/10.1016/j.ienj.2019.100811

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/10.4236/health.2019.115044

Pereira, R. A., de Souza, F. B., Rigobello, M. C. G., Pereira, J. R., da Costa, L. R. M., & Gimenes, F. R. E. (2020). Quality improvement programme reduces errors in oral medication preparation and administration through feeding tubes. British Medical Journal Open Quality, 9(1), e000882. http://dx.doi.org/10.1136/bmjoq-2019-000882

Singh, G., Patel, R. H., & Boster, J. (2023, May 30). Root Cause Analysis and Medical Error Prevention. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570638/

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 1621-1632. https://doi.org/10.2147/IJGM.S289452

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Tuti, T., Aluvaala, J., Malla, L., Irimu, G., Mbevi, G., Wainaina, J., & English, M. (2022). Evaluation of an audit and feedback intervention to reduce gentamicin prescription errors in newborn treatment (ReGENT) in neonatal inpatient care in Kenya: A controlled interrupted time series study protocol. Implementation Science, 17(1), 32. https://doi.org/10.1186/s13012-022-01203-w

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 2028. https://doi.org/10.3390/ijerph17062028

Vifladt, A., Ballangrud, R., Myhr, K., Grusd, E., Porthun, J., Mæhlum, P. A., & Odberg, K. R. (2023). Team training program’s impact on medication administration, teamwork and patient safety culture in an ambulance service (TEAM-AMB): A longitudinal multimethod study protocol. British Medical Journal Open, 13(1), e067006. http://dx.doi.org/10.1136/bmjopen-2022-067006

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. Bio Med Central Nursing, 19(1), 1-9. https://doi.org/10.1186/s12912-020-0397-0