Assignment: Root-Cause Analysis and Safety Improvement Plan
Assignment: Root-Cause Analysis and Safety Improvement Plan
Root-Cause Analysis and Safety Improvement Plan
Nurses can play an effective and active role in implementing safety improvement measures and plan to reduce the ever-increasing concerns about patient safety due to sentinel or adverse events like medication errors in healthcare settings. By performing a root cause analysis, nurses can systematically identify causes of problems in their facilities, especially process and system-check failures. The root cause analysis (RCA) tool and its processes end with the formulation of recommendations aimed at enhancing patient safety. Medication errors contribute to over 250,00 deaths in the U.S. each year and increase the cost burden of care (Afaya et al., 2021). These errors also lower the quality of care and are considered sentinel events that may never be compensated by the Centers for Medicare and Medicaid Services (CMS) through its value-based purchase model. The purpose of this paper is to describe the root cause of medication errors in the healthcare setting and propose best practice strategies to address the issue. The paper also develops and suggests an effective safety improvement plan to achieve safe medication based on various organizational resources.
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Analysis of the Root Cause
Medication administration errors (MAEs) remain a core concern for nurses, especially those working in acute and progressive care units. In particular, preventing these errors needs careful monitoring and reflection on working processes, especially the medication administration process that starts with prescribing to dispensing and administering to patients as well as getting feedback. In this case, nurses working in the unit experienced challenges in administering drugs to patients at the scheduled or appropriate time. On several occasions, nurses reported the incidents to the nursing manager and compiled corresponding records in the electronic medical administration record (EMAR) system (Jessurun et al., 2021). The reported incidents did not entail negative effects but their recurrence constitutes significant risks to patients and the unit based on the delicate nature of patients it handles. The root cause of the situation was lack of following the scheduled time to give patients their medications and documentation them at each occurrence. Nurses were not following the scheduled time since they did not get sufficient medications on time as a result of the workload and ineffective communication in the dispensing medication process. The implication is that nurses were administering medications to patients at the wrong time that included past the scheduled time based on the acuity of their conditions. The lack of offering medications on time constituted wrong-time medication administration error (WTMAE); a core patient safety concern that required an effective corrective and intervention plan.
Evidence from Existing Literature on WTMAEs
Wrong-time medication administration errors (WTMAEs) are a critical concern and entail giving a medication or drug at an earlier or later time than required or mandated by the treatment plan. Many prescriptions mandate taking medications at certain hours to enhance the therapeutic effects and reduce possible side effects. Consequently, WTMAEs have significant effects on patients and can lead to treatment delays, harm, deterioration of patients’ condition, and the need for more treatment interventions. Such effects impact not just the provider but also patients leading to an added cost burden. Therefore, healthcare organizations need to address the issue, especially in acute settings.
Existing literature has addressed the issue of drug administration errors (DAEs). Medication administration errors emanate from failures to observe one of the six rights in the drug administration process (Hydari et al., 2019). These include the right medication, right dose, right time, right route, and right documentation. As such, for effective administration, nurses should comply with all six rights. In the current situation, the nurses in the unit failed to comply with the requirement of the right timing of drug administration. Ignoring any of the rights is tantamount to endangering or harming the overall health and response of patients to the disease being treated.
Several factors can hinder the administration of drugs at the right time. In their study, Raja et al. (2019) identify a lack of sufficient personnel, limited experience, and ineffective communication as causes of such events. Furthermore, the incomprehensibility of prescription writings and ineffective workload distribution can also lead to such errors. In their study, Furnish et al. (2021) assert that communication issues, lack of awareness about time-bound critical medications, and limited process optimization can lead to giving medications at the wrong time. Again, work-related issues, lack of professionalism, and organizational safety culture also influence the occurrence of such errors. Time error is more prevalent than other types and emanates from a lack of training, ineffective communication, interruptions, and a lack of organizational policy guidelines. These factors form the most prevalent causes of medication administration errors in general.
In this case, several root causes may have increased the probability of the WTMAEs in the unit. These include the delicate nature of patients in the unit and the high levels of workload for each nurse (Hydari et al., 2019). Again, interruptions and distractions as well as ineffective communication necessitated the error in the unit. While the nurses in the unit cannot control the delicate nature of patients, the organization and providers can address the other causes like workload and ineffective communication, and limited awareness.
Application of Evidence-Based Strategies
Healthcare providers and organizations can mitigate and address medication administration errors based on their root causes. In this case, the wrong-time medication administration errors in the facility are work-related or systematic since, despite reporting and documentation, the unit’s managers have not taken effective measures to address them. The first evidence-based strategy is to optimize the electronic record system to improve workflow efficiency. According to Furnish et al. (2021) having special marks on drugs whose administration should happen at a certain time ensures that employees pay close attention to their offering to patients. This means that having an automated dispensing and administration system would help reduce such errors. Westbrook et al. (2020) opine that using electronic systems reduces errors. Again, process optimization is necessary due to the workload that the nurses have in the unit and the delicate nature of the patients that they serve. Process optimization requires increased integration of health technologies like computerized physician order entry (CPOE) and clinical decision support systems (CDSS). Nurses should also have effective handover measures through better communication as part of process optimization approaches to prevent the occurrence of these errors.
Reporting and effective documentation of errors allows the organization and provides to analyze the effects of each event. Presently, the practice in the unit entails certain ways of reporting errors and creating records. However, the unit needs additional measures to analyze and evaluate the MAEs. These could include a supportive environment based on the organizational culture, expert analysis, and effective responsive systems. As such, having an effective reporting mechanism and analysis system is critical to optimizing workflow to reduce such events.
Interruptions can be a core concern in reducing MAEs. Studies by Kavanagh et al. (2020) and Huckels-Baumgart (2021) illustrate that having separate rooms to prepare medications or drugs can lower the possibility of interruptions and associated errors. Again, Laustsen et al. (2018) suggest that focusing on their tasks, prioritizing their duties, and collaborating among specialists can lower interruptions. Imperatively, having a working culture that maintains the professional conduct of nurses on their tasks and normalizing communication that reduces any chatting during the drug administration process can help the unit overcome the issue at hand.
Improvement Plan with Evidence-Based and Best-Practice Strategies
An improvement plan that enhances safety and quality care founded on evidence-based and best practice strategies is an inevitable part of the unit to reduce these errors. The first strategy is to optimize the EMAR system to show drugs that have time limitations. Through this approach, the nurses will understand the importance of time management and reduce the possibility of wrong time MAEs (Jessurun et al., 2021). The strategy also tackles the issue of workload as nurses may be missing on time due to difficulties in getting sufficient time and even access to medications.
The second aspect is to solve the issue of interruption. The unit can address this by altering the drug administration process and changing the organizational culture. The administration process needs specialists and the facility should limit external interferences. The unit can ensure that there are special rooms and zones for the preparation of medications (Laustsen et al., 2018). These zones enhance concentration, privacy, and minimal activities so that the provider can focus on the medications.
The third measure is having an effective reporting analysis of the MAEs in the unit. The current reporting regime is highly ineffective and requires an overdue overhaul to improve its components. The reporting component should be part of the working or organizational culture at the facility. The measure will lead to better optimization and reduction of workload in the unit.
The implementation of these four measures requires a transformative approach where employees are willing and ready to embrace changes. The changes will ensure that they have a new behavioral approach to the issue and culture that supports and integrate the professional competencies of nurses in drug administration. The goal of such transformation would be to have an effective work culture with better communication protocols and leveraging health information tools and technologies to reduce medication administration errors (Mutair et al., 2021). The measures should reduce aspects like interruptions and their associated effects on the giving of medications. The organization and unit should also train nurses and establish a timeline for implementing these changes or measures.
Existing Organizational Resources
Organizational resources like expertise from nurses and other providers can enhance the implementation of the safety improvement plan to attain positive patient results. Again, having reliable data and research on the needs is essential in developing and implementing the suggested measures with increased accuracy and effectiveness in results and outcomes. The organization should also leverage information technology specialists and experts to train nurses on behavioral change aspects to improve process optimization and focus on their tasks (Kawade et al., 2020). The facility should tap resources from even external entities to develop this program and safety plan to reduce medication administration errors (MAEs). More importantly, the organization should incentivize and motivate its current workforce to implement process optimization measures to reduce medication administration errors.
Conclusion
Wrong-time medication administration errors (WTMAEs) are prevalent in progressive and acute care units. Administering medications to patients at the wrong time lowers their therapeutic impact and can lead to harm, exacerbate their health condition and result in more strain on the unit and hospital in general. Errors in this unit happen due to the delicate nature of patients and the increased nurse workload. These errors can also occur because of interruptions. Based on evidence-based approaches and best practices, the paper develops and suggests an improvement plan that entails several aspects like reporting process optimization and having quiet zones through a transformed work culture.
References
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. BMC health services research, 21(1), 1-10. DOI: 10.1186/s12913-021-07187-5.
Jessurun, J. G., Hunfeld, N. G. M., Van Rosmalen, J., Van Dijk, M., & Van Den Bemt, P. M. L.
A. (2021). Effect of automated unit dose dispensing with barcode scanning on medication
administration errors: an uncontrolled before-and-after study. International Journal for
Quality in Health Care, 33(4), mzab142. DOI: 10.1093/intqhc/mzab142.
Furnish, C., Wagner, S., Dangler, A., Schwarz, K., Trujillo, T., Stolpman, N., & May, S. (2021).
Evaluation of medication administration timing—Are we meeting our goals? Journal of Pharmacy Practice, 34(5), 750–754. DOI: 10.1177/0897190020905456.
Huckels-Baumgart, S., Baumgart, A., Buschmann, U., Schüpfer, G., & Manser, T. (2021).
Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: A prospective observational study. Journal of Patient Safety, 17(3), 161-168. DOI: 10.1097/PTS.0000000000000335.
Hydari, M. Z., Telang, R., & Marella, W. M. (2019). Saving patient Ryan—can advanced
electronic medical records make patient care safer? Management Science, 65(5), 2041-2059. DOI:10.1287/mnsc.2018.3042
Kawade, S., Doke, P., & Verma, A. K. (2020). Assessment of Prescription Medications for
Indoor Patients and Effect of Interventions in a Medical College Hospital. Global Journal on Quality and Safety in Healthcare, 3(4), 139-143. DOI: 10.36401/JQSH-20-3.
Laustsen, S., & Brahe, L. (2018). Coping with interruptions in clinical nursing—A qualitative
study. Journal of Clinical Nursing, 27(7-8), 1497-1506. DOI: 10.1111/jocn.14288.
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A., Mohaini, M. A., Al Mutairi, A., Rabaan, A.
A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines (Basel, Switzerland), 8(9), 1-12. DOI: 10.3390/medicines8090046
Raja, R., Badil, B., & Ali, S. (2019). Wrong-time medication administration errors and its
association with demographic variables among nurses in tertiary care hospitals, Karachi. Journal of the Dow University of Health Sciences (JDUHS), 13(1), 30-36.
DOI: https://doi.org/10.36570/jduhs.2019.1.637
Westbrook, J. I., Sunderland, N. S., Woods, A., Raban, M. Z., Gates, P., & Li, L. (2020).
Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study. BMJ Health & Care Informatics, 27(3), 1
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Root-Cause Analysis and Safety Improvement Plan
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For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
Create a viable, evidence-based safety improvement plan for safe medication administration.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
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Professional Context
Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.
Scenario
For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:
The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
Instructions
The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.
Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
Create a feasible, evidence-based safety improvement plan for safe medication administration.
Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.
Assessment 2 Example [PDF].
Additional Requirements
Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to current APA style.
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