Root-Cause Analysis and Safety Improvement Plan
Root cause analysis is the act of examining where the problem started and the causes associated. Before that, identifying a problem is essential, then scrutinize for the causes and possible solutions. The solutions are meant to improve the results; however, root-cause analysis is done again to identify room for further improvement if the desired results are not met again. This essay will discuss the medication errors, identify its root cause, and establish an improvement plan that will help the organization minimize medication errors.
Analysis of the root cause
Several people are victims of medication errors in the United States, to which some may die as a result. The national center of biotechnology information estimates that about 8000 people die every year from medication errors in the United States (World Health Organization, 2016). Additionally, thousands of other patients experience complications as a result of medication errors. Also, the cost of reversing these medical errors is expensive for both the facility and individuals. Medication errors can cause physical and psychological pain while handling their adverse effects due to economic and physical implications.
Medication errors cause trust and dissatisfaction with the health services they receive. Patients conclude that the health care workers are incompetent and untrained well when they commit the medical error of administering the drugs inappropriately. However, as this might not be true, it is hard to convince the patients. They look for alternative places or alternative service providers after such occurrences due to a lack of trust. Medication errors, among other medical errors, can cost an organization in a big way. Nonetheless, medication errors are preventable by enacting several measures to ensure competency.
According to Schroers, Ross & Moriarty (2020), there are several causes of medication errors. At Lafayette Villa nursing home, a root-cause analysis conducted by the nurse in charge revealed several reasons for the medication errors in the facility. Some of the causes identified include; poor communication between doctors and fellow doctors and with nurses. During the break in the communication line among the healthcare providers, the patients suffer because they don’t get the care they deserve and a series of possible medical errors also come into play. The other issue that was identified was the medical abbreviations, which at one point, were almost similar. During drug administration, the nurse could give a particular drug, confusing it with another; hence the patient suffers the consequences of these errors. Similarly, the drug names can be closely related by pronunciation; therefore, it was found that sometimes nurses interchange some drugs hence causing medication error.
Lastly is the burnout associated with overworking. Medical staff burnout stood out and was identified as the main root cause of medication errors compared to the rest. It contributed to the highest number of medication errors. Understaffing caused burnout to the nurses, which became a distraction from performing their duties well. Medication errors occur due to a violation of the five patient rights, which are; right patient, right time, right dose, right drug, and right route (Gilani, 2020). Nurses were overwhelmed on several occasions, giving drugs to the wrong patients or giving drugs using the wrong administration route.
Adding up to the burnout, distractions of nurses also contribute to medication errors. Studies have shown that nurses are most vulnerable to distractions than the rest team of the profession in line of duty (Johnson et al. 2017). Hence, it predisposes them to commit more mediation errors than the rest disciplines. Sources of distractions can be family members, alarm bells from the patients, new admissions, emergencies, and calls from other faculties. As much as it is part of the duties nurses do, they are distractions when administering medications. Solving part of the interruptions and distractions is employing enough staff who will be assigned to specific tasks.
Improvement plan with evidence-based and best practice strategies
From the identified causes of medication errors in Lafayette Villa Nursing Home, the improvement plan includes; fostering proper communication skills among the doctors, doctors and nurses, and the health care providers with the patients. Communication is essential in diagnosing, prescribing, and even during the administration of drugs. Training healthcare providers on effective communication, medication errors, and other missed information will be solved. All the healthcare providers are also advised to use only standard medical abbreviations, both accepted by the medical board and in the organization, to avoid confusion that leads to medication errors. Additionally, nurses are urged to be more careful and attentive in handling drugs that bear names almost similar to avoid interchanging.
In the issue of burnout, the organization expected to act swiftly to endure that staffing is enough or the activities are manageable. Allocating sufficient staff help in reducing burnouts, also reduce medication errors. Nonetheless, it is essential that during drug administration, the nurses have a second pair of eye checks to confirm the patient’s five rights. The second pair of eyes is to ensure drug administration is done right, which reduces medication errors. The other most crucial plan is that nurses should learn to involve the patient. They should know all the medications they are receiving, the dosages, frequency, and the time frame. If a different drug were given by chance, they would be attentive to alert the caregiver, hence reducing the potential medication errors.
Other supportive measures include team empowerment in the organization, whereby at Lafayette Villa Nursing Home, staff should be recognized for good performances. Outstanding performers should be recognized and awarded. Through this, staff are motivated hence adding more efforts in their performance and the urge to be recognized reduces the medication errors as everyone strives to be the best. A leader can also be appointed who is vocal and supportive. The leader will be tasked to provide direction to each staff and serve their challenges at a personal level. The staff are less likely to mess up when they are followed closely as they will be careful in everything to main tin their reputation. Leaders can enable the nurses to work effectively, deliver in a timely manner, and to reduce the possibilities of errors.
Lastly, in the improvement plan, the organization can seek to improve or change the environment. The distractions and interruptions come as a result of the environment and can further be improved by adjusting the environment. Family members can cause distractions, alarm bells from the patients, new admissions, emergencies, calls from other faculties; therefore, there can be a controlled inflow of the family members or visitors during drug administration time. Simultaneously, whenever there are new admissions, it should not distract any procedure in then wards. Emergencies are critical, and as much as they can be distractions, the organization needs to place other individuals who will handle emergencies only. Similarly, frequent calls and alarm bells should be assigned to individuals to avoid distractions during medical procedures when administering medications.
Existing Organizational Resources
Scrutinizing the organizational potential is important in executing the improvement plan, and it can be identified by evaluating the resources that an organization has. Some of the potential resources are knowledge and skills. Some of the problems can be solved using the staff knowledge and skills acquired during their training for the profession like ensuring the five right of the patients is followed at all times when administering medications. Additionally, the resources in terms of materials also matter in the facility in that it will affect the extent to which an improvement plan is executed. The resources can be outsourced outside the organization, but only when need be as it is cheaper using the already existing resources in the organization.
Root cause analysis and safety improvement plan are essential in every organization to identify problems, which helps solve each of the problems. The root-cause analysis is conducted by skilled personnel in an organization to bring out specific priorities in terms of solving the problems in an organization. At Lafayette Villa Nursing Home, several problems were identified to be the causes of medication errors; the environment, distraction, burnouts, poor communication, drugs bearing similar names, and confusion occurring from similar abbreviations. Improvement plan and safety improvement plan comes after conducting root-cause analysis to ensure the problems identified are solved. Every organization needs to regularly conduct the root-cause analysis and safety improvement plan because it promotes the organization to produce results, hence gaining a competitive advantage.
Gilani, S. A. (2020). Practices of Nurses in Administration of Safe Medication. I, 18(3), 32.
Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., … & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of nursing management, 25(7), 498-507.
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 Safety.
World Health Organization. (2016). Medication errors. World Health Organization.
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