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

NURS-4020-Assessment-2-Root-Cause-Analysis-and-Safety-Improvement-Plan-1

Root-Cause Analysis and Safety Improvement Plan

Medication administration errors are common across the United States (US). These errors can be in dosage amount, dosage time, or inappropriate doctor prescriptions. According to Sarasin et al. (2020), one common thing in all medication errors is that they can be prevented through appropriate operating procedures and safety measures. According to data, over 1.3 million individuals in the US are affected by medication errors yearly, costing about 40 billion USD annually (Single Care, 2021). A medication error was observed at Mass General Brigham (MGH), whose root cause has been analyzed in this assessment to propose a safety improvement plan. The error was in the medication dosage amount as Registered Nurse (RN) Betty overdosed on a complex patient with Chronic Kidney Disease (CKD). 

Root Cause Analysis of the Overdosage at MGH

Many subsequent events have been analyzed in this case. A patient died in the observation of Betty, irrespective of all necessary measures taken by her on the same day of the medication error. Betty was relatively depressed on the day of the medication error, which also led to her inattentiveness toward the other patients. Secondly, she forgot to follow the medication protocol and procedure, leading to errors. She was supposed to read the dosage of morphine prescribed by the doctors. The patient had severe pain leading to a hurry in medication and the ultimate error caused by Betty. The issue was identified by Betty herself when she checked on the patient after 10 minutes. The patient’s skin got pale by then, showing an error. 

The problem highly affected the medication administration at MGH as additional measures were taken by the management to prevent such errors in the future. The patient was highly affected as he could have gone very critical or worse. The incident of medication error directly influenced the patient family and nurses being directly in contact with the patient (Abbasinia et al., 2019). RN Betty was strictly penalized by the hospital administration at MGH for the incident, but her license was not canceled due to the subsequent patient death earlier that day (Malik et al., 2021). 

Root Causes or Elements

Based on the analysis of all events, two elements or root causes have been identified that caused the event of medication overdosage. The first root cause was a human error from Betty as an RN who did not check the prescription before providing medication to the patient. The second root cause identified in the analysis is the hospital environment and staff behavior on that particular day, as they were disappointed with the loss. Both elements suppressed medication safety to allow error (Schroers et al., 2020). Hence, a safety issue in the clarity of standard operating procedures at MGH needs to be addressed to reduce the chances of such events in the future. 

Application of Evidence-Based Strategies

Human errors and deviation from the standard operating procedures and medication protocols have been identified by Sarasin et al. (2020). The research also stated that appropriate nurse training regarding medication procedures was essential to prevent medication errors at healthcare institutions. According to a research report, establishing a culture of safety and eliminating the culture of blame was an evidence-based method to prevent medication errors in healthcare institutions (Rodziewicz & Hipskind, 2020). According to Sessions et al. (2019), medication errors are primarily the result of human error. The research proposed that using appropriate medication procedures to implement prescribed medication was an evidence-based strategy to improve the safety conditions at healthcare institutions by eliminating medication errors. Lahti et al. (2022) established that using Electronic Health Records (EHR) was an evidence-based intervention for preventing medication administration errors. 

Elimination of Safety Issues from Strategies

Three main strategies have been identified in the literature. These include promoting a culture of safety, identifying protocols and procedures for medication administration, and the use of technology like EHR. The development of a culture of safety makes every team member conscious of their decisions and the impact these decisions can have on patient safety, reducing the likelihood of medication errors (Rodziewicz & Hipskind, 2020). Using procedures and standardized protocols and their implementation at MGH is also an effective method to reduce medication errors. The rationale is that nurses will review medication prescriptions for specific complex patients every time before medication, reducing the chances of medication errors (Sessions et al., 2019). The use of EHR is an effective way to minimize human error through the use of computerized writing. The prescriptions by doctors are often not readable, causing trouble for nurses. EHR will ensure that no medication errors result from human errors in reading and writing prescriptions at MGH in the future (Lahti et al., 2022). For example, the nurse will read the medication name, time, and dosage on EHR as a standard procedure at MGH, leading to no medication error. 

Evidence-Based Safety Improvement Plan

The evidence-based strategies identified from the literature have been analyzed in the context of MGH. A plan to improve the safety of patients at MGH through these strategies has been devised. The plan will include three main actions or procedures at MGH to enhance patient safety. The Plan is likely to be an evidence-based plan for addressing the issue of a medication error at MGH as it has been developed in coherence with the evidence-based strategies from the literature. The recommended actions to be undertaken as part of this evidence-based plan are as follows:

  • The first action is to conduct a seminar on the importance of safety for all nurses and other medical staff. The seminar proceedings will include a specific guide for MGH medical staff to promote a culture of safety in the workplace (Rodziewicz & Hipskind, 2020). 
  • The second evidence-based action in the plan is the implementation of EHR at MGH, which will contain data on all patients, their medical prevalence, prescribed medication history, current medication details, and time of administrating medication (Lahti et al., 2022). 
  • The third auction is the development of medication administration procedures. In this new procedure, the nurse will be able to collect the prescribed medication for a patient and its dosage after confirmation from the administrator at the pharmacy. The medication administrator will confirm the data of medication provided by the nurse on EHR before issuing the medicine (Sessions et al., 2019). 

Rough Timeline and Goals

The proposed actions are all evidence-based and supported by research. It has been estimated that the implementation of EHR will be started immediately at MGH. The overall implementation of all the above actions will be complete by the first half of next month. The primary goal of implementing the plan is to eliminate the medication errors at MGH related to overdosage of medicine or any other human error by the nurse. The plan also aims to increase patient safety and a culture of safety at MGH. 

Organizational Resources

Both human and financial resources will be used during the plan’s implementation. The leadership skills of Senior RNs at MGH will be used during the seminar for the culture of safety. The EHR will be purchased, with an estimated cost of 20,000 USD, approved by the financial manager at MGH. RNs, general managers, financial managers, and all other stakeholders will need to get involved in the plan to make its implementation effective. The role of nurses is most important to be leveraged for plan improvement (Simonetti et al., 2021). The nurse training to use EHR and follow procedures will be conducted by the senior RNs who directly report to the general manager at MGH. 

The technical staff is an important personnel resource of MGH after RNs who will be implementing EHR at the institution. At last, the agreement of the boards of directors on the following actions is needed that will be gained through the general manager. Hence, all resources at MGH are valuable and can be prioritized based on their high need to low (Simonetti et al., 2021). The highly needed resource is the board of directors, whose agreement will initiate the project and approve the finances required to purchase EHR technology. RNs, technical staff, and other managerial personnel are prioritized in high to low-need order for implementation of a safety improvement plan after the approval from the boards of directors (Delaforce et al., 2023). 

Conclusion NURS 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

A medication-related error has been analyzed at MGH in this assessment. It was observed that the deviation from the protocols and general human negligence were the main reasons behind the error, as found in the route cause analysis. The research recommended that improvement in safety culture, use of protocols, and implementation of EHR were evidence-based strategies to reduce medication errors. The implementation of EHR at MGH has been proposed along with two other actions to improve patient safety. It was found that the organizational resources available at MGH were enough to implement the proposed safety improvement plan. 

References

Abbasinia, M., Ahmadi, F., & Kazemnejad, A. (2019). Patient advocacy in nursing: A concept analysis. Nursing Ethics27(1), 141–151. https://doi.org/10.1177/0969733019832950

Delaforce, A., Li, J., Grujovski, M., Parkinson, J., Richards, P., Fahy, M., Good, N., & Jayasena, R. (2023). Creating an implementation enhancement plan for a digital patient fall prevention platform using the CFIR-ERIC approach: A qualitative study. International Journal of Environmental Research and Public Health20(5), 3794. https://doi.org/10.3390/ijerph20053794

Lahti, C. L., Kivivuori, S.-M., Lehtonen, L., & Schepel, L. (2022). Implementing a new electronic health record system in a university hospital: The effect on reported medication errors. Healthcare10(6), 1020. https://doi.org/10.3390/healthcare10061020

Malik, R. F., Samardžić, M. B., Amajjar, I., Hilders, C. G. J. M., & Scheele, F. (2021). Open organizational culture: What does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique. BMJ Open11(9)https://doi.org/10.1136/bmjopen-2020-045515

Rodziewicz, T., & Hipskind, J. (2020). Medical error prevention. NCBI Bookshelf; StatPearls Publishing. http://www.saludinfantil.org/Postgrado_Pediatria/Pediatria_Integral/papers/Medical%20Error%20Prevention%20-%20StatPearls%20-%20NCBI%20Bookshelf.pdf

Sarasin, D. S., Brady, J. W., & Stevens, R. L. (2020). Medication safety: Reducing anesthesia medication errors and adverse drug events in dentistry part 2. Anesthesia Progress67(1), 48–59. https://doi.org/10.2344/anpr-67-01-10

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Sessions, L. C., Nemeth, L. S., Catchpole, K., & Kelechi, T. J. (2019). Nurses’ perceptions of high‐alert medication administration safety: A qualitative descriptive study. Journal of Advanced Nursing75(12)https://doi.org/10.1111/jan.14173

Simonetti, M., Cerón, C., Galiano, A., Lake, E. T., & Aiken, L. H. (2021). Hospital work environment, nurse staffing and missed care in Chile: A cross‐sectional observational study. Journal of Clinical Nursing31(17-18), 2518–2529. https://doi.org/10.1111/jocn.16068

Single Care. (2021, May 2). Medication errors statistics. The Checkup. https://www.singlecare.com/blog/news/medication-errors-statistics/#:~:text=The%20cost%20of%20medication%20errors

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