NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

Nurses play a central role in addressing quality improvement in healthcare and one of the approaches is through identifying root-causes of medication errors and proposing methods of addressing them. The incident of concern is a medication error whereby the nurse administered the wrong dosage to a patient leading to temporary harm. This error occurred in a large urban hospital in the medical wards. The event triggered the need for a root-cause analysis of the factors leading to wrong dosage. This paper presents a root-cause analysis of the event, discusses some evidence-based and best-practice strategies to address it, and proposes a safety improvement plan to address the root-causes with the support of the available organizational resources.

Analysis of Root-Cause

The identified event is a medication error whose root cause could be one or more factors. Medication errors are common the health care industry and they cause harm and death to numerous patients each year. Medication errors cause adverse drug events and every year, 5% of patients in the hospital experience an adverse drug event (Giardina et al., 2018). In addition to adverse drug events, medication errors generally reduce the quality of care and safety of patients hence affecting the reputation of the organization. Some events may attract litigation against the health care organization and the nurse involved and hence medication errors are costly. The incident described in the introduction led to an overdose of the prescribed drug leading to poor health outcomes and extended hospital stay. The event was detected by another nurse when the patient started exhibiting symptoms of drug overdose. A review of the patient records showed that the attending nurse had administered two times the required dose. The patient developed acute confusion, anxiety, and hyperventilation. The event can be related to human error and systems failure and hence this analysis seeks to correct these two categories of causal factors.

The incident was investigated by a team of four, including the nurse manager, charge nurse, quality manager, and attending physician. The review of patient records revealed that the indicated dosage in the prescriptions was doubled in the nurse’s entry of the administered dosage. Therefore, the nurse administered the wrong dosage and entered in the patient records. This overview presented an opportunity to discuss the issue with the involved nurse. The nurse stated that the error occurred as a genuine mistake and there must have been some confusion. The analysis then included environmental and system factors.

An overview of medication errors and the organizational environment shows that the error can be attributed to high nurse workload and burnout. A review of the medical ward showed that there was a serious shortage of staffing hence nurses handled more acuity than they should. According to Johnson et al. (2017), a leading cause of medication errors is nurse burnout and distraction. In this case, a high workload for the nurse led to confusion of the medication dosage. Distractions also occur when the nurse is interrupted when in the process of medication preparation and administration. Staff workload led to low concentration in the process of medication administration and resulted in the medication error.

Another cause of medication errors such as the identified incident is the standard processes implemented in the health unit. Systemic medication errors are those caused by the design of the system as well as equipment and technology used. The medication administration process allows nurses to prepare medication at the patient’s bedside. Bedside medication preparation presents inherent risks in nurse distraction by the patient, other patients in the ward, and other staff. In general, the stated event was caused by human error contributed by workload and distractions as well as the standard processes of medication administration in the medical ward.

Application of Evidence-Based Strategies

Medication errors have been linked to both interruptions and nurse workload. A study conducted in Australia showed that 99% of all medication events had interruptions (Johnson et al., 2017). These interruptions were mostly from other nurses and often non-care related. The frequency of interruptions was associated with procedural failures and clinical errors. Similarly, research showed that as nurse-patient-ratio increases, there is a decrease in quality of care and number of medication errors related to nursing workload (Qureshi et al., 2017). These causes of medication error show the need for interventions to reduce distractions and nurse workload. The proposed strategies will address these two root causes.

Various strategies may be used to reduce nurse distractions and workload. First, distractions and interruptions may be reduced through design of a process to ensure that nurses are not interrupted during the medication preparation process. This process will ensure that nurses can acquire a private space where they can prepare medication away from the patient’s bedside and then go to the patient for administration. Regarding nurse workload and process for medication administration, staffing and nurse training could be implemented to reduce workload and increase the competence of nurses in offering care. The two proposed strategies can be consolidated into a safety improvement plan using the existing organizational resources to improve patient safety by limiting medication administration errors.

Safety Improvement Plan

The proposed improvement plan presents two major approaches to the medication administration challenge. The first approach is to implement the ‘sterile cockpit’ concept to the process of medication preparation to reduce nurse interruptions. This concept is borrowed from the aviation industry whereby nonessential activities are eliminated from the cockpit during critical phases of the flight (Ruby, 2016). Applied to medication administration, this strategy avails a safe space for nurses to go and prepare medications away from all nonessential activities. Previous research shows that the strategy led to 42% reduction in medication errors (Ruby, 2016). The objective of this strategy is to limit interruptions as much as possible and create an environment where the nurse can concentrate on the crucial task at hand. This strategy will be implemented by creating a medication preparation room whereby nurses will only be allowed if they are carrying out this specific activity and interactions will be kept at minimum.

The second strategy to be used for this root cause is to implement staff recruitment and training in reducing medication errors. Since staffing levels have been established as low in the organization and contribute to medication errors, increasing the number of staff in the organization can effectively reduce the number of errors. Regular staff awareness and training in patient safety have also been established as causing a significant decrease in the rates of medication errors (Di Simone et al., 2018). This strategy thus aims to increase the number of competent nurses to reduce human error emanating from knowledge deficit. Wrong dosage could emanate from the nurse’s inexperience and lack of knowledge in the medication administration processes. In this case, therefore, the intervention will reduce the risk of such errors by increasing nursing staff knowledge and competence.

Existing Organizational Resources

Implementation of the proposed strategies relies on leveraging existing resources to produce the best results. The timeline for this improvement plan includes the initial investment in the sterile cockpit and staffing needs as well as ongoing training of all nurses to enhance care quality. The safe space for medication preparation will be designated in a room adjacent to the medical ward where nurses can retreat and prepare medications without interruptions. The hospital facility has that space and furnishing and equipment are the required resources. Secondly, the organization needs financial investment in recruiting new staff and training existing ones. Financial investment in a recruitment program is required whereby the actual number of nurses and their qualifications are to be determined. An available resource is the experience of many charge nurses and nurse managers who can train the existing nurses and new recruits on patient safety and reduction of medication error risks. Overall, the organization has the financial and training capacity to implement both strategies of the improvement plan.

Conclusion

Medication errors are common occurrences causing adverse events and near misses in the health care industry. The described medication administration error is attributed to human error and systemic challenges in the medication administration process. The proposed strategy will address staff distractions by providing a private space where nurses can concentrate on medication preparation before administration. Moreover, staffing levels will be improved to reduce the risk of errors made due to high staff workload and burnout. Leveraging the existing organizational resources, the program will effectively address the current medication administration error and prevent similar and related errors in the future.