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Capella 4020 Assessment 2

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    Capella 4020 Assessment 2

    Capella 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

    Student Name

    Capella University

    NURS-FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name

    Date

    Root-Cause Analysis and Safety Improvement Plan

    Root cause analysis (RCA) is an organized approach for figuring out the root reasons for a specific issue or occurrence, such as a concern with patient safety. Instead of concentrating on immediate issues, it aims to uncover the underlying reasons. The RCA process involves describing the problem, gathering relevant information, identifying contributing factors, identifying root causes, generating suggestions, putting a safety improvement plan into action, and then monitoring and assessing the plan’s effectiveness (Abela, 2021). This paper is based on the root cause analysis of medication errors in the Vila Health organization. 

    Analysis of Root Causes in Vila Health Organization 

    In the medical-surgical unit of Vila Health organization, a medication error incident occurred involving nurse Sarah, who was responsible for administering medications to multiple patients. One of the patients, Emily, a 24-year-old female hospitalized with pneumonia, received an incorrect medication dosage. Due to distractions and a heavy workload, Sarah mistakenly prepared an intravenous dose of Amoxicillin instead of the prescribed oral dosage. Shortly after receiving the medication, Emily experienced adverse reactions resembling anaphylaxis, including low blood pressure and dizziness. Fortunately, there were no lasting consequences, and the patient recovered. This incident shed light on medication administration errors (MAEs) in healthcare settings.

    Medication errors can be investigated in the context of Root Cause Analysis (RCA) to determine the underlying reasons and contributing variables that resulted in the error. Any event that could potentially be avoided during the administration of medicine that results in inappropriate medication usage or patient harm is referred to as a medication error. The processes of prescribing, transcribing, dispensing, administering, and monitoring medications can all result in it. The wrong drug administration, the wrong dosage, the wrong patient receiving the medication, or failure to provide the medication when it is necessary, resulting in a life-threatening situation. 

    Capella 4020 Assessment 2

    Root Cause Analysis (RCA) of the above event can be conducted to investigate the factors contributing to the medication error and the impact on those involved. The incident was primarily caused by Nurse Sarah’s distraction and heavy workload, leading to the incorrect preparation and administration of the medication. Other factors, such as inadequate double-checking processes or lack of system safeguards, may also contribute to the error. The incident could have had severe consequences if not promptly addressed. Additionally, the healthcare team involved may have experienced emotional distress and professional implications.

    Application of Evidence-Based Strategies

    Applying evidence-based and best-practice measures is essential when addressing a safety problem or sentinel event related to medication administration. Some best practice strategies, to address safety concerns in the administration of medications may address;

    • Reducing interruptions during Medication Administration: Interruptions during the administration of medications raise the possibility of medication mistakes. Abela (2021) states that the risk of errors may be decreased by minimizing interruptions, such as by creating distraction-free areas or developing communication procedures. It might be helpful to provide education and awareness to healthcare personnel about the significance of uninterrupted medication administration.
    • Use of Technology and Automation: The literature highlights how employing technology and automation might help minimize medication errors. For instance, Abela (2021) showed through a thorough study that barcode scanning devices may dramatically reduce medicine delivery errors. Implementing barcode medication administration (BCMA) systems can improve medication safety by reducing errors related to medication selection, dose, and patient identification.

    Capella 4020 Assessment 2

    • Double-checking methods: Medication errors might be caused by improper double-checking methods. Technology-based tools, including barcode scanning or electronic systems that demand double-checks, can help increase compliance with this practice (Boussat et al., 2021).
    • Processes for Medication Reconciliation: According to Miller (2021), medication inconsistencies and adverse events might result from improper or insufficient medication reconciliation. Establishing a comprehensive review and verification of medication orders and patient-reported medicines at admission, transfer, and discharge as part of a rigorous medication reconciliation procedure. To avoid medication errors, healthcare personnel should ensure effective communication throughout transitions.
    • Ongoing Learning and Training: Knowledge gaps and insufficient training contribute to drug mistakes. Provide healthcare workers with continuing education and training programs. Regular competency audits may help in identifying and addressing a person’s specific training needs (Miller, 2021).

    Evidence-Based Safety Improvement Plan 

    Based on the sentinel event that occurred in Vila Health Organization, several policies and procedures can be adopted to prevent its recurrence, a systematic and comprehensive strategy known as a safety improvement plan should be implemented. This plan prioritizes a system-based investigation through RCA to understand the underlying causes of the event. It ensures a proactive and organized approach to enhance patient safety and continuously improve the organization’s processes and practices. Following policies and procedures can be adopted to prevent medication errors and enhance patient safety,

    • Medication Administration: Implement and enforce the “Six Rights of Medication Administration” policy, which includes ensuring the right patient, right medication, right dose, right route, right time, and right documentation. This policy emphasizes the importance of double-checking medications before administration to minimize errors 
    • Ongoing Training and Education: Develop a comprehensive training program for nurses that focuses on medication safety, including proper medication administration techniques, error prevention strategies, and recognition of potential adverse reactions. Regular education sessions and competency assessments should be conducted to ensure nurses’ knowledge and skills remain up to date.
    • Minimizing Distractions: Create designated areas or provide dedicated time for medication administration to minimize distractions for nurses. This can include implementing distraction-free zones, reducing interruptions during medication rounds, and promoting a culture of focus and concentration during medication administration.

    Capella 4020 Assessment 2

    • Staffing and Workload Management: Evaluate staffing levels and workload to ensure adequate nurse-to-patient ratios, which can reduce the likelihood of errors due to increased stress or rushing. Consider hiring additional staff or redistributing workload to ensure nurses have sufficient time and resources to safely administer medications.
    • Standardized Processes and Protocols: Establish standardized processes and protocols for medication administration, including clear guidelines for medication preparation, verification, and administration. This can help eliminate variations in practice and reduce the risk of errors.
    • Medication Reconciliation: Implement a robust medication reconciliation process, ensuring accurate and up-to-date medication information is obtained and documented during transitions of care. This helps identify any discrepancies or potential interactions that could lead to errors.
    • Technology Solutions: Explore the use of technology solutions such as barcode medication administration (BCMA) systems, automated dispensing cabinets, and electronic prescribing systems. These technologies can enhance medication safety by reducing errors related to medication selection, dosage, and patient identification.

    To address the above sentinel event in Vila Health Organization and prevent its recurrence, a systematic and comprehensive strategy known as a safety improvement plan should be implemented. This plan prioritizes a system-based investigation through root cause analysis to understand the underlying causes of the event.

    Existing Organizational Resources

    To leverage existing resources within the Vila Health Organization and support the implementation of the safety improvement strategy for safe medication administration, the following actions can be taken:

    1. Primary healthcare providers: Encourage healthcare providers, including nurses and doctors, to promptly report incidents and participate in the safety improvement efforts. Foster a culture of open communication and emphasize the importance of reporting to facilitate timely action and continuous improvement.
    2. Nurse leaders: Support nurse leaders in their role as advocates for patient safety. Provide them with the necessary resources, such as education and training modules, to enhance their knowledge and skills in medication safety practices. Empower them to lead and facilitate the implementation of the safety improvement plan among their teams.
    3. Drug safety officer or pharmacist: Involve the expertise of the drug safety officer or pharmacist in guiding the execution of the safety improvement strategy. They can provide insights into best practices for medication safety, offer guidance on implementing interventions, and coordinate efforts related to medication administration.
    4. Quality improvement team: Collaborate with the organization’s quality improvement team to ensure alignment of the safety improvement plan with overall quality improvement goals. They can assist in data collection, analysis, and evaluation to monitor the effectiveness of the plan and identify areas for further improvement.

    Capella 4020 Assessment 2

    In terms of leveraging existing resources, the following can be prioritized based on their potential impact:

    • Barcode Medication Administration (BCMA): If Vila Health Organization already has a BCMA system in place, utilize it to enhance medication safety by verifying medication accuracy at the bedside.
    • Data analytics: Utilize data analytics capabilities to analyze medication errors, identify patterns and trends, and target interventions for continual improvement.
    • Medication safety policies: Review and update existing medication safety policies to align them with evidence-based best practices, identifying opportunities for improvement.
    • Incident reporting systems: Promote the use of incident reporting systems to record and analyze medication-related occurrences, fostering a culture of reporting and learning from errors.
    • Personnel and human resources: Allocate resources for training and educational materials to provide thorough and continuous training on drug safety procedures for healthcare personnel. Encourage interdisciplinary collaboration to improve communication and enhance the quality of care.

    Conclusion

    Medication errors are a significant global concern in healthcare settings. Researchers commonly use Root Cause Analysis (RCA), which is a valuable approach used in hospital settings to improve medication errors and enhance patient safety. It investigates the causes of sentinel events and implements corrective action plans to mitigate future occurrences. RCA enables hospitals to prioritize patients’ health needs and establish goals aligned with patient requirements. By conducting an RCA analysis, hospital management gains clarity on the necessary steps to prevent future mishaps resulting from causal factors, and ultimately enhance patient safety by minimizing medication errors. It encourages a culture of learning, accountability, and patient safety, which eventually results in improved methods for medication administration and improved patient outcomes.

    References

    Abela, G. (2021). Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. Journal of Tissue Viability, 30(3), 339–345. https://doi.org/10.1016/j.jtv.2021.04.004

    Boussat, B., Seigneurin, A., Giai, J., Kamalanavin, K., Labarère, J., & Francois, P. (2021). Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers. Journal of Patient Safety, 17(8), e1194–e1201. https://doi.org/10.1097/pts.0000000000000456

    Martin-Delgado, J., Martínez-García, A., Aranaz, J., Valencia-Martín, J. L., & Mira, J. (2020). How much of root cause analysis translates into improved patient safety: A Systematic Review. Medical Principles and Practice, 29(6), 524–531. https://doi.org/10.1159/000508677

    Mardawi, G. H. A., Rajendram, R., Alowesie, S. M., & Alkatheri, M. (2021). Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini–Root Cause Analysis and Action. Global Journal on Quality and Safety in Healthcare, 4(1), 27–43. https://doi.org/10.36401/jqsh-20-25

    Miller, K. K. (2021). Comparing the Effects of Traditional Education and Root-Cause Analysis on Nursing Students’ Attitudes About Safety Culture and Knowledge of Safe Medication Administration Practices. Nurse Educator, Publish Ahead of Print. https://doi.org/10.1097/nne.0000000000001126

    Niñerola, A., Sánchez-Rebull, M., & Hernández-Lara, A. B. (2020b). Quality improvement in healthcare: Six Sigma systematic review. Health Policy, 124(4), 438–445. https://doi.org/10.1016/j.healthpol.2020.01.002

    Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D. L., Kontopantelis, E., Bower, P., Campbell, S., Haneef, R., Avery, A. J., & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, l4185. https://doi.org/10.1136/bmj.l4185

    Singh, G., Patel, R. H., & Boster, J. (2023). Root cause analysis and medical error prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK570638/

    Smith, A., & Plunkett, E. (2019). People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia, 74(4), 508–517. https://doi.org/10.1111/anae.14519