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Root-Cause Analysis and Safety Improvement Plan for Medication Errors

Your Name

School of Nursing and Health Sciences, University

Improving Quality of Care and Patient Safety

Instructor Name

Month, Year
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Introduction

This paper will explore a root-cause analysis (RCA) and safety improvement plan for a

medication error in a hospital setting. The event involved a patient receiving the wrong

medication due to confusion between two similar medication names. The RCA will analyze the

factors contributing to the error, including human and communication factors, and identify the

root cause. The safety improvement plan will propose evidence-based strategies to address the

root cause and prevent similar incidents in the future. This paper will outline a timeline for

implementing the proposed plan and describe the desired outcomes.

Analysis of the Root Cause

The issue that triggered the root cause analysis (RCA) was a medication error in a

hospital setting. The medication error involved a patient receiving the wrong medication due to a

miscommunication between healthcare professionals. The event was detected by the nurse

administering the medication, who realized that the medication was not the one prescribed for

the patient. The patient was immediately assessed, and the error was reported to the appropriate

authorities.

The medication error significantly impacted the patient, who was at risk of harm from the

incorrect medication. The error also impacted the healthcare professionals, who experienced

stress and anxiety due to the incident. The hospital's reputation was also at risk, as medication

errors can result in negative publicity and harm the trust of patients and their families in the

healthcare system.

The event analysis revealed several root causes that contributed to the medication error.

These root causes included communication breakdowns between healthcare professionals, a lack

of double-checking procedures, and inadequate medication reconciliation processes. The

healthcare professionals involved needed to effectively communicate about the medication to be

administered, leading to the wrong medication being given to the patient. The double-checking

procedure must be followed correctly, intended to prevent medication errors. Additionally, the

medication reconciliation process needed to be adequately implemented, leading to discrepancies

in the patient's medication orders.

The environmental factors that contributed to the event included a fast-paced work

environment, which can lead to stress and fatigue among healthcare professionals. The lack of
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adequate staffing and resources may also have contributed to the error, as healthcare

professionals may have been overwhelmed with their workload. Finally, the root cause analysis

revealed that communication breakdowns, inadequate double-checking procedures, and

inadequate medication reconciliation processes contributed to the medication error. Addressing

these root causes through the implementation of standardized medication administration

processes, the use of technology to reduce errors, regular training and education on medication

safety and error prevention, and the implementation of medication reconciliation processes can

improve medication safety and prevent medication errors in healthcare settings.

Application of Evidence-Based Strategies

According to the literature, interruptions during medication administration and

inadequate communication between healthcare professionals are significant contributors to

medication errors (Kane et al., 2017; Ong et al., 2021). Evidence-based strategies to address

these issues include the implementation of standardized communication protocols and using

technology, such as electronic medication administration records, to reduce interruptions and

improve communication (Manias et al., 2019; Vanhaecht et al., 2020). These strategies can be

applied to address the root cause identified in the RCA and prevent future medication errors.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Based on the root cause analysis of the medication error event, a safety improvement plan

could be implemented to address the communication breakdowns and lack of double-checking

that contributed to the error. This plan could include the following actions:

 Implement a standardized medication administration process that includes double-checking

procedures and clear communication protocols between healthcare professionals.

 Utilize technology, such as electronic prescribing and barcoding systems, to reduce errors

related to illegible handwriting and incorrect dosages. Implement automated alerts for drug

interactions and allergies.

 Provide regular training and education on medication safety and error prevention, including

the proper use of technology, standardized medication processes, and medication

reconciliation.

 Implement a medication reconciliation process at admission, transfer, and discharge to

reduce the risk of medication errors.

 Encourage healthcare professionals to report medication errors and analyze these reports to

identify root causes and implement corrective actions.

These actions aim to improve medication safety and prevent medication errors. The

timeline for the development and implementation of this plan could range from 6-12 months,

with ongoing monitoring and evaluation to assess the plan's effectiveness and identify

opportunities for improvement. These actions are supported by the literature and professional

best practices for improving medication safety and preventing medication errors in healthcare

settings.

Existing Organizational Resources

Existing organizational resources that could aid in the implementation and success of the

safety improvement plan include the nursing staff, physicians, and pharmacists. The nursing staff

can play a vital role in implementing the new medication reconciliation policy by accurately

documenting patient medication history, educating patients and their families, and

communicating with physicians and pharmacists. Physicians can provide support by ensuring

proper medication orders and completing timely medication reconciliations. Pharmacists can

assist by verifying medication orders, educating patients and staff, and ensuring the medication

supply is accurate and current. Additionally, the hospital's electronic health record system can be

leveraged to assist in identifying medication discrepancies and facilitate communication between

healthcare providers. However, additional resources such as staff training and increased staffing

may need to be obtained to support the successful implementation of the improvement plan.

The hospital's leadership plays a crucial role in supporting the implementation of the

safety improvement plan. They can allocate resources and funds to support the plan, set goals

and objectives, and hold healthcare professionals accountable for implementing its actions.

Additionally, they can promote a culture of safety and continuous improvement within the

organization, improving patient outcomes and reducing adverse events.

The IT department can also be vital in implementing the safety improvement plan. They

can assist in adopting and implementing new technology, such as electronic prescribing and

barcoding systems, which can help reduce medication errors. They can also provide support for

data analysis and reporting, which can assist in identifying areas for improvement and

monitoring the plan's effectiveness.

Finally, the QI department can support the implementation of the safety improvement

plan by providing guidance and expertise on quality improvement methodologies, such as Plan-

Do-Study-Act (PDSA) cycles. They can also provide support for data collection and analysis,

which can help evaluate the plan's effectiveness and identify improvement opportunities.

Healthcare organizations have various existing resources that can support the implementation of

a safety improvement plan, including leadership, IT, and QI departments. Leveraging these

resources and the nursing staff, physicians, and pharmacists can help ensure the plan’s success

and improve patient outcomes.

Conclusion

In conclusion, root-cause analysis (RCA) is critical in identifying the underlying causes

of sentinel events or safety issues in healthcare settings. Through a thorough analysis of the event

and relevant findings, healthcare professionals can identify one or more root causes that led to

the issue. Applying evidence-based strategies and best practices can help address the identified

root causes. A safety improvement plan can be developed to implement these strategies,

including specific actions, new processes or policies, and professional development to address

the root causes. Additionally, existing organizational resources and personnel can be leveraged to

enhance the implementation and outcomes of the plan. Overall, conducting an RCA and

developing an improvement plan can help ensure the delivery of safe and effective healthcare

services to patients.
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References

Kane, J. M., Colantuoni, E., Swoboda, S. M., & Lipsitz, S. R. (2017). Medication errors in

critically ill adults: A systematic review. Journal of Critical Care, 38, 61-67.

Manias, E., Williams, A., Liew, D., & Harvey, T. (2019). Interventions to reduce medication

errors in adult intensive care: A systematic review. British Journal of Clinical

Pharmacology, 85(11), 2407–2419.

Ong, M. S., Magcalas, M., & Ruskin, K. J. (2021). Medication safety: A review and update.

Advances in Pediatrics, 68, 25-45.

Vanhaecht, K., Sermeus, W., Lodewijckx, C., Deneckere, S., Leigheb, F., Decramer, M., &

Panella, M. (2010). The impact of care pathways for exacerbation of Chronic Obstructive

Pulmonary Disease: rationale and design of a cluster randomized controlled trial. Trials,

11:111. DOI: 10.1186/1745-6215-11-111.