Analysis of the Root Cause of medication Errors
Root cause analysis refers to a systematic process utilized in the identification of the root causes of an event or problem and developing a practical approach to prevent recurrence (Okes, 2019). A root cause analysis was for the issue of medication error in a nursing facility was comprehensively conducted. The following paper comprehensively explores medication errors and describes evidenced-based techniques of reducing medication errors and presents a safety improvement plan founded on the utilization of the existing organizational resources to eliminate medication errors.
Analysis of the Root Cause of medication Errors
According to Anderson and Abrahamson (2017), medication errors annually account for the death of more than 251,000 people in the US. Additionally, medication errors are currently the third leading cause of death, making it a significant healthcare issue in the 21st century (Anderson & Abrahamson, 2017). In the United States, there are thousands of patients who suffer the adverse effects or complications emanating from medication errors without reporting. These adverse effects include physical and psychological suffering and pain, which may lead, decreased patient satisfaction, and reduced trust in the global healthcare system (McMahon, 2017). Medication errors have a significant negative impact on the patient, healthcare providers, and the general economy. According to Rodziewicz & Hipskind (2019) currently results in a loss of close to $20 billion annually, which strains the healthcare system. It is, therefore, fundamental to develop a comprehensive solution to the current healthcare problem. A medication error refers to any preventable event that may lead to or result in patient harm while the medication is in the control of healthcare providers, patients, or consumers (Anderson & Abrahamson, 2017).
Due to the steady rise in the incidences of medication errors at Clarion Courts Skilled Nursing Facility, the facility administrator ordered a root cause analysis to model the problem and develop an appropriate solution comprehensively. The charge nurse was accorded the responsibility of conducting the root cause analysis and investigating the issue. The charge nurse held general discussions and interviews with general nursing staff and gathered valuable information about staff issues, which contributed to medication errors. The charge nurse found out that the nursing staff was overworked, understaffed, and frequently distracted, resulting in increased incidences of medication errors. Since the organization was experiencing a shortage of nurses, the available ones had a higher workload resulting in frequent distractions while performing duties.
Consequently, a higher workload negatively affected their mental state in addition to the distractions originating from physicians, patients, and colleague nurses. The chances of a medication error significantly increased if a nurse was distracted during med pass. When any of the five fundamental rights of dispensing medication (right drug, right patient, right route, correct dose, and right time) was contravened, a medication error occurred. A team of nurses within the facility also disclosed that cases of wrong drug and wrong time were on the rising trend, especially during the day when nurses were distracted and overworked.
According to Anderson and Abrahamson (2017), nurses are at a very high risk of making medication errors when under stress or constant pressure. Consequently, the interruption or distraction of a nurse increased the chances of medication errors by 60% (Anderson & Abrahamson, 2017). However, interruption of nurses may occur between 6.5 times to 14 times per hour during the day shift, which further enhances the risks of errors (Thomas, Donohue-Porter, & Fishbein, 2017). In research to determine the fundamental causes of distractions within the hospital setting, nurses completed the medication distraction observation sheet. After the analysis of data, the results outlined the top ten distraction sources, which included; interaction with visitors and patients, telephone calls, alarms, missing medications, wrong doses, external noise, and physicians (McMahon, 2017). These distractions increase the mental burden, thus triggering the loss of focus and consequently contravention of the five rights of administering medication (McMahon, 2017).
Improvement Plan with Evidence-Based and Best-Practice Strategies
close to 90% of all the medication errors occurred due to the distraction of nurses. The creation of the “No disturbance zones” around hospital sections where medication is prepared is highly recommended. Implementation of such a strategy ensures that the focus of the nurses is not shifted from the fundamental responsibility. These zones also allow the nurses to effectively focus on looks like medications, black labeling, and correct labeling, thus reducing the incidences of errors. Consequently, McMahon (2017), through a clinical trial, found out that the use of highlighted decorative aprons, safety bested posted signs, and sashes reduced medication errors by 88% by decreasing work interruptions.
Team empowerment is another fundamental strategy that can be implemented at Clarion court to decrease medication errors. Enhancing the safety and wellbeing of the staff members as they carry out their duties is fundamental in ensuring they work according to the organizational policies (Shrivastav & Sachdeva, 2018). When team members feel acknowledged and valued by the organization, they tend to harmoniously collaborate rather than resisting thus fostering positive patient healthcare outcomes. Transformational leadership is vital for the nursing facility since it inspires the willingness of staff to operate to deliver to the best of their mandate. For instance, if the nursing assistants in the healthcare organization felt motivated and valued, they would commit themselves to perform diligently and completing their duties in a timely, accurate manner. This would also allow nurses to focus on their jobs. Communication and motivation of members of staff through recognizing their work and rewarding the outstanding members of the organization ultimately results in positive outcomes concerning medication errors (Shrivastav & Sachdeva, 2018).
Consequently, environmental adjustments and fostering awareness should be incorporated into the improvement plan. Promoting the awareness of co-workers, patients, and family members that a nurse is preparing or administering medication would be vital in reducing medication error (Brown, Garza, & Moore, 2018). The use of signs such as “Do not Disturb” on med charts decreases the chances of interrupting a healthcare professional while preparing a medication hence reducing the chances of a medication error (Brown, Garza, & Moore, 2018). Additionally, if co-workers are aware, they may assist the nurse by addressing the patient’s needs within their practice while the nurse is engaged in preparing the medication. For instance, if a patient requests for restroom assistance, a certified nursing assistant can assist instead of having to call the nurse. However, if the patient’s needs are beyond the scope of a nursing assistant, another nurse who is available of support may be invited to help to address the patient’s needs. Shrivastav & Sachdeva (2018) suggest that environmental adjustments like regulating the noise levels enhance the nurse’s concentration.
Furthermore, the implementation of hourly rounding meets the needs of the patient—this aids in eliminating call lights that may distract nurses while preparing and administering medications. Implementation of hourly rounding enhances concentration levels of nurses while handling drugs hence reducing errors (Shrivastav & Sachdeva, 2018).
Identifying and utilizing organizational resources when implementing an improvement is fundamental towards positive healthcare outcomes, safety enhancement, and reduction of healthcare costs. The first part of the improvement plan requires members of staff to utilize their skills and knowledge to foster awareness of the fundamental role of nurses in handling medications. Through this recognition of this role, they would assist nurses by completing other tasks around them. Consequently, environmental adjustments, such as having safety zones with signs such as ‘Do not disturb’ to foster awareness. These signs may be created in a precise and prompt manner without high organizational cost. Other environmental interventions such as incorporating “No Pass Zone” that is already existing, in the facility would positively contribute to the regulation of the noise level. Consequently, enhancing communication, collaboration, and trust among the current staff as an essential resource would also contribute to the reduction of medical errors. Lastly, the existing in-house resources such as IV pumps, bed alarms should be systematically improved to decrease the general cost of implementing the safety improvement plan.
In conclusion, medication errors are currently the third leading cause of death in the United States. Due to the steady rise in the cases of medication errors at a nursing facility, a root cause analysis was conducted to investigate the issue and develop the preventive measure. The investigation identified distraction/interruption as the main contributing factor to the errors that nurses experienced. The paper presents evidence-based mechanisms such as the use of identifiers, team empowerment, and environmental adjustments to aid in addressing the issue. An improvement plan was to develop to decrease medical errors among nurses within the healthcare institution: this plan incorporated environmental modifications, fostering teamwork, and staff awareness.
References