Medication Errors root cause analysis
Introduction
Medical errors may negatively affect the patient’s health causing extended health costs, hospitalization, or even death. According to the World Health Organization data, costs associated with medical errors alone account for one percent of the worldwide health expenditure. According to Bajracharya et al. (2019), about 2.6 million deaths occur as a result of medical errors, and about 42.7 million people become victims of medical errors worldwide in a year. As a result of these effects, improvement in the quality of healthcare across the whole world has been of critical importance. This paper will analyze why medical occur and what can be done to improve the situation. The paper will be based on a case of a 71-year-old windowed patient who recently arrived at the hospital with an acute kidney injury and uncontrolled hypertension. The paper will look into the possible cause of these errors and propose possible interventions that can be put in place to avoid such instances from happening.
Background
The patient under study is a 71 hears old windowed lad who arrived at the healthcare facility with an acute injury on the kidney and uncontrolled hypertension. During her stay at the hospital, temporary hemodialysis was administered to her while her anti-hypertensive medications were also adjusted, improving her clinical status. She was prescribed amlodipine (Norvasc), doxazosin, torsemide, and metoprolol upon discharge.
After three months, her health situation started getting worse. The patient started experiencing fatigue, lethargy, personal differences, slow movements, and un uncontrolled blood pressure. She was diagnosed with depression and anxiety, leading to alprazolam and citalopram as an addition to her existing condition. Soon, she presented more serious symptoms, including bradykinesia, blank faces, and a shuffling gait. During a C scan, elevated creatine levels and acute abnormalities were noted.
After a physical examination of the pill bottles the patient was taking, it was noted that the patient had been taking an antipsychotic medication known as Navane (thiothixene) instead of an anti-hypertensive Norvasc known as amlodipine. She had been taking the wrong medication for the last three months. The thiothixene medication was discontinued, and her health status improved.
It was also revealed that the amlodipine dose prescribed was more than 10 mg recommended per day, and the starting dose was also higher than required. Despite being hospitalized twice for three months, many healthcare workers had overlooked her medication use resulting in a multi-level error.
Possible causes and interventions
Medical errors in the healthcare system can occur due to many reasons. Such reasons include and not limited to the patient’s medical history, time pressures, inadequate staffing, negligence by health practitioners during assessments, and nurse’s unawareness of their patient’s history. In this case, the patient is elderly and with an acute kidney injury. Older people are more likely to experience kidney failure (Gardner, 2018). As the patient age, the remaining glomeruli effectiveness is affected by the narrowing renal arteries, reduced effectiveness of the nephrons, and reduced size of the kidney. As a result, elderly people with such a condition requires a thorough assessment and monitoring of the patient’s progress. Such can, however, only be achieved if the number of health practitioners is enough to attend to a large number of patients. As revealed in the case, it doesn’t appear that a thorough assessment of the patient’s intakes was done, even having gone through two medications within three months. The lack of this assessment resulted even in more harm to the patient as it took longer to correct the mistakes. A possible cause that may have resulted in this situation would be the lack of sufficient nurses to attend to a large number of people visiting the hospital. Where the ratio of patients to nurses is very high, there is a high possibility that such errors can occur and fail to be detected on time due to the excessive workloads. Martin (2015), argues that the ability of ethical practice in a situation where the nurses are understaffed is very difficult.
The origin of the error, in this case, is at the pharmacist dispensation. The mistake resulted in the extension of the patient’s hospitalization because the medication administered was incorrect. Such a mistake would have happened because of time pressures, and the pharmacist administering the medications to the patient did it in a hurry failing to realize that the medications were different from the ones recommended. According to Da Silva and Krishnamurthy (2016), the pharmacist’s ratio to technicians may be as high as 4:1 depending on the local regulations, and their errors can result from the increased number of verified prescriptions and long shifts. In the face of pharmacist fatigue, pharmacist errors are also likely to be highly likely.
Thirdly, it is also possible that the pharmacist who administered the medications was also less experienced or undertrained. Perhaps, the pharmacist did not understand the medication. The case also reveals that the starting medication for the patient was also higher than recommended, meaning that the pharmacist was most likely inexperienced or incompetent. Thiothixene carries a high risk of death for older people and is typically started at a low dosage of 2 mg. Comparing this requirement to the 20 mg prescribed, it is clear that there could be a problem of incompetency. The possible causes for this pharmacist error, therefore, surround the situations of understaffing, fatigue, and under training.
Interventions
To avoid such situations from happening again, a few proposals can be made. First, healthcare organizations need to form a culture that allows consultations between the pharmacists and the prescribers. Previous studies have indicated that the majority of the physicians indirectly act as if they are superior to the pharmacists (Moore, Kennedy & McCarthy, 2014). This presumption creates strained relationships between the prescribers and the pharmacists, denying them the opportunity to consult in case of such occurrences.
In this context, if the healthcare had a good culture where the pharmacists can freely engage in discussion with the prescribers about the dosage prescribed, perhaps the patient would not have received the wrong dosage. It is recommended that pharmacist departments, specialists, hospitalists, and outpatient providers should regularly review their respective indications and medications and also counsel the patients about the medications subscribed. The prescribers should regularly perform medication reconciliations, especially where patients present unusual symptoms.
Health care providers should also embrace computerized software and electronic health records that allow institutions to provide details relating to prescriber identification, pharmacy location, directions for administration, and the dates filled. Such a system would make it easy to track such incidences and determine the appropriate course of action. The system would also go a long way in promoting accountability in the healthcare systems. A requirement that the prescriber and the nurse must review and document the medications before discharging the patient must be completed independently to minimize such occurrences.
Healthcare facilities must embrace efforts to improve care transition to their patients, a culture of physician communication, and error discussion. Electronic health care records should also be used to review prescription history for the patients. Medical reconciliations should be mandatory for all hospitals. In instances where a patient responds unusually to medications, it is recommended that a medication review be carried out, and the pills bottle review should also be part of the initial evaluations.
According to Allen (2010), hospitals also need to put in place systems to assist in error recognition. The leaders of healthcare facilities should focus on creating a culture of efficient communication, humility among the health practitioners and specialists, a spirit of teamwork, and the opportunity to learn from previous mistakes. Though repetition of errors may not be tolerated, the leaders of health facilities should also create a working environment in which the health practitioners do not fear to report errors when they occur even under reasonable situations. Health practitioners who repeatedly commit medical errors should be subjected to mandatory training to prevent more errors from claiming the patient’s lives.
Conclusion
Medical errors can cause regrettable harm to the patients. It is, therefore, imperative for healthcare facilities to carry out root cause analysis and undertaking preventive actions to minimize the adverse impact of such errors. The possible causes of the medical error analyzed in this paper were summarized as a lack of sufficient staff, time pressure, lack of communication between the pharmacist and the drug prescribers, and incompetent. Recommended interventions included the adoption of electronic health records that allow institutions to provide details relating to prescriber identification, pharmacy location, directions for administration, and the dates filled. Healthcare leaders are encouraged to focus on creating a culture of efficient communication, humility among the health practitioners and specialists, a spirit of teamwork, and the opportunity to learn from previous mistakes.
References
Moore, T., Kennedy, J., & McCarthy, S. (2014). Exploring the General P practitioner–pharmacist relationship in the community setting in which I reland. International Journal of Pharmacy Practice, 22(5), 327-334.
Gardner, E. (2018). Drug adherence and symptom management in older people. British Journal of Community Nursing, 23(11), 560–565. doi:10.12968/bjcn.2018.23.11.560
Martin, C. J. (2015). The effects of nurse staffing on quality of care. MEDSURG Nursing, 24(2), 4–6. Retrieved from EBSCOhost
Da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Journal of community hospital internal medicine perspectives, 6(4), 31758.
Bajracharya, D. C., Karki, K., Lama, C. Y., Joshi, R. D., Rai, S. M., Jayaram, S., … & Upadhyaya, M. K. (2019). Summary of the International Patient Safety Conference, June 28—29, 2019, Kathmandu, Nepal. Patient Safety in Surgery, 13(1), 36.
Allen, M. C. (2010). Medical error prevention and root cause analysis. CME.