A root cause analysis is a tool that answers the question of what causes the problem
Root cause analysis
A root cause analysis is a tool that answers the question of what causes the problem. It helps in the identification of the origin of a problem that sets in motion the entire cause and effect reaction. This analysis aims to identify these problems to come up with preventative measures (Charles et al., 2016). With a significant number of substances flooding the market, it is credible that mistakes may happen when a physician prescribes or dispenses drugs. These medication errors will continue to increase unless the root cause of this problem is addressed. Multiple medical programs have come up with measures to reduce and successfully curb medication errors from their hospital, but more actions are necessary to end this complication. This paper is a root cause analysis based on a hospital setting. It will look into the root cause of medication errors in the hospital, apply evidence-based strategies to address the issues, create a viable, evidence-based safety plan, and also identify any existing organizational resources that can be used to improve the safety plan implemented.
Analysis of root cause
A medication error is any error in between when the physician prescribes a drug, and when the patient receives it. Generally, medication errors occur during ordering, documenting, dispensing, transcribing, and administering. Each year, 7000 to 9000, people lose their lives to medication errors in the US alone (Mohiuddin, 2019). The problem can, therefore, not be taken lightly. Also, hundreds of thousands do not report the adverse effects that are brought about by the medication. Medication errors can lead to unnecessary hospitalization, congenital disabilities, organ failure, and even death.
In a hospital setting, medication errors happen in the course of treatment. For instance, the intravenous anticoagulant heparin is a high-risk medication that is commonly used in an inpatient setting. The use of this drug requires regular monitoring of blood’s ability to clot and weight-based dosing. If the doses are too high, it could lead to bleeding complications, and if the doses are too low, it could increase the risk of internal clots. If an incorrect dosage of the drug is administered, this is a medication error. If applied correctly, the medication decreases the blood clotting ability and prevents harmful clots from forming inside the blood vessels.
Medication errors, such as these, are caused by several underlying factors that can either be contextual or human. There are contextual factors such as a decrease in staffing, heavy workloads, lack of supervision, and mishandling of new technologies (Badruddin, Gul, Roshan, Dias, & Muhammad, 2019). Also, human factors such as standards of care, policies, procedures, and processes that, if not correctly followed, could lead to medication errors. Human factors are the most common and basic cause of medication errors (Ayorindea & Alabi, 2019). For instance, the previous example could be a result of a knowledge-based error in which the physician does not know how much dosage is necessary. It could also be as a result of poor communication where there is poor documentation and poor labeling of drugs.
Improvement plan with evidence-based strategies
The medication error in this setting is an administration error, which is the responsibility of physicians, nurses, and pharmacists (Rehan & Bhargava, 2015). Administration error occurs when the medicine is being taken or given to the patient. To reduce medication administration errors, some hospitals are adopting technology to aid in medicating the patients. The implementation of barcode medication administration and electronic medication administration record has been noted to have a significant effect on the number of medication errors in hospitals.
The electronic medication administration record was developed to enhance communication between the nurses and the pharmacist. On the other hand, bar code medication administration was introduced to reduce administration errors. The bar code technology helps the administration of medicine by confirming the medication of the patient at bedside and ensure the five rights of medication administration are followed (Truitt, Thompson, Blazey-Martin, NiSai, & Salem, 2016). This technology provides the correct drug, dose, route, time, and patient during administration, reducing the risk of medication error significantly.
The application of this technology in hospitals can be implemented by administrators as soon as funding is available. It is also crucial to understand that nurse educators must be part of the implementation process to educate the nurses regarding the new technology (Torjesen, 2018). With its application, patients will be able to enjoy the five rights of medication administration that the technology assures. This will thereby reduce the number of medication errors that occur during the administration phase. The timeline of this plan would fall within four weeks, which would primarily consist of training nurses, physicians, and pharmacists on how to integrate the new technology with their work.
The lack of pharmacological knowledge is also a factor leading to medication error. To eliminate this factor, the care staff and nurses can be introduced to collaborative learning activities by nurse educators and pharmacists (Kosari, 2018). Constant exposure to professional development activities combined with on-site training regarding medications they administer prevents incidences of the medication error.
Existing organizational resources
The medical administrators in the hospital play a vital role in eliminating medication errors. One of the root causes is the lack of pharmacological knowledge, administrators who are also the policymakers should develop new policies. These new policies would see critical players such as pharmacists interacting more with nurses and teaching them about the common drugs they give their patients. Administrators can implement strategies such as pharmacists have to be in constant rotation, especially in the busy departments such as the ER, rather than being enclosed in the pharmacy. This also shows that pharmacists are also essential organizational personnel who play a crucial role in the implementation of this plan.
Another solution is the application of technology to ensure that the drugs administered to the patient are correct. This is in terms of the five rights of medication. To implement this plan, one of the necessary personnel is the nurse educators. They are tasked with informing and training the existing nurses on how to use the technology best to achieve the desired outcomes. Additionally, there is a need for an external monitor whose role is to evaluate the progress of the implemented plans continuously. The monitors will determine if the plan is working as expected or it deserves some changes.
In conclusion, by identifying the underlying causes of medical errors, it becomes easier to prevent, monitor, and respond to them as a way to upgrade healthcare standards. This translates to being able to provide primary care to patients at lower costs and teach caregivers how to protect the patient better. The use of any medication in the wrong way, in terms of the five rights of administration, is considered as a medication error. The underlying factors of this error can either be human factors or contextual factors. Based on the situation given in this paper, the focus in on the former. To reduce these forms of administration errors, the hospital can choose to adopt new technology such as the barcode medication administration and electronic medication administration record. These two are noted to reduce medication errors significantly. Also, training nurses and other caregivers on pharmacological knowledge share the same results. Medical administrators, pharmacists, and nurse educators play an essential role in implementing these plans meant to reduce medication errors in a hospital setting.
References
Ayorindea, M. O., & Alabi, P. I. (2019). Perception and contributing factors to medication administration errors among nurses in Nigeria. International Journal of Africa Nursing Sciences, 11. doi:10.1016/j.ijans.2019.100153
Badruddin, S., Gul, R., Roshan, R., Dias, J., & Muhammad, K. P. (2019). Underlying Factors of Medication Errors at a Tertiary Care. Emergency medicine and critical care.
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Safety Surgery. doi:10.1186/s13037-016-0107-8
Kosari, S. (2018). Medication errors in nursing homes: the role of pharmacological knowledge. Intensive Critical Care Nurse, 1(1).
Mohiuddin, A. (2019). Patient Safety: A Deep Concern to Caregivers. Innovations in Pharmacy, 10(1). doi:10.24926/iip.v10i1.1639
Rehan, H. S., & Bhargava, S. (2015). Medication Errors Are Preventable. Journal of Pharmacovigilance. doi:10.4172/2329-6887.S2-005
Torjesen, I. (2018). Using technology to tackle medication errors. The Pharmaceutical Journal.
Truitt, E., Thompson, R., Blazey-Martin, D., NiSai, D., & Salem, D. (2016). Effect of the Implementation of Barcode Technology and an Electronic Medication Administration Record on Adverse Drug Events. Hospital Pharmacy, 51(6), 474-483. doi:10.1310/hpj5106-474