Root-Cause Analysis and Safety Improvement Plan Essay Assignment Paper

Root-Cause Analysis and Safety Improvement Plan

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Root-Cause Analysis and Safety Improvement Plan
It was just a few months ago that a medication error happened within our healthcare organization. A new medical officer joined the organization and a few moments after another client had no longer required the medicine, he placed sulfonylureas in the cage containing enoxaparin. The problem was resolved before it had the opportunity to have disastrous effects. The paper seeks to examine this scenario and analyze it. A strategy for implementing evidence-based practice, as well as improvement approaches and organizational resources, will be included as well.

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Analysis of the Root Cause
In this situation, the patient needed enoxaparin to be administered. The nurse who was responsible for administering the medications headed to the pharmacy and removed the medication from its container, just as he usually did. Practitioners are required to input medicines into the system in accordance with patient care and data, as stipulated by the facility’s regulations. After scanning the medicine, he received an error message stating that the medication was incorrect on two occasions. Because he had hurried and the device was prone to function poorly, he occasionally utilized the alternative of override to keep inputting the other medicines. He administered the medicine in accordance with the prescribed dose of 1.5 ml; nevertheless, after a short period, the nurse saw that the patient was looking agitated, disoriented, and wobbly. Because of the sudden onset of clinical symptoms of hypotension, the nurse felt that the medicine had to be the cause of this occurrence. He proceeded to the pharmacist’s station and handed her one amp of D50, which is considered to be effective in the treatment of hypoglycemia in the event of an unexpected low blood glucose level. The problem was investigated further and it was discovered by the nurse that medicine had been placed there by mistake.
It is possible that negligence and failing to adhere to the facility’s procedures, among other things, resulted in the current situation. When used correctly, the system’s significance is that it is intended to minimize similar medication errors from occurring. Despite the fact that the system is notorious for misbehaving, the nurse should have investigated whether the mistake was legitimate or the result of a system malfunction. Furthermore, the pharmacist disregarded the medication storage standards that were in place at the facility. The inability of the pharmacist to arrange the medicines according to their kind was the root of the problem.
Moreover, the nurse failed to adhere to the five rights of medicine delivery as recommended. The five rights are intended to guarantee that the appropriate medicine is administered to the appropriate patient at the appropriate dose, at the appropriate time, and through the appropriate channel (Martyn et al., 2019). The nurse may be alerted to the inaccuracy and prevent the medication from being administered if this procedure is followed.
It appears that inadequate communication with the pharmacist has an impact on routine, which is critical in the promotion of coordinated care. Studies have found that good communication is critical in encouraging cooperation among clinicians and improving coordinated care. The pharmacist was inexperienced, and her error might be ascribed to the individual who helped her become acquainted with the job. Aside from that, environmental variables such as a client not requiring medicine, medications being of comparable appearance and size, and nurse practitioners being preoccupied all contributed to the problem.
Human errors that contributed to the incident include the pharmacist placing the medicine in the incorrect location and the nurse failing to verify the medicine before administering it to the patient. Despite the fact that drugs may be kept in identical containers and seem the same, the health data system and laboratory instruments should detect the mistake before it happens. In addition, the equipment is old and ineffective. Because it occasionally displays errors when none were present, the nurse assumed it was the same situation and did not raise the issue with the doctor. On closer examination, it becomes clear that the root cause is a combination of faulty equipment, inadequate knowledge, ineffective communication, and failure to follow a specified model of care.
Application of Evidence-Based Strategies
A large proportion of medication errors are attributed to communication breakdowns and human error. Medicines may be misidentified by a nurse or other healthcare worker, particularly if their appearances are similar. As pointed out by Breuker et al. (2017), good communication skills between healthcare providers may minimize over 80 percent of medication blunders. Because of the absence of effective communication methods, as shown in the example, the probability of a drug mistake is increased. Supplemental steps must be taken to minimize the likelihood of medication errors, including the establishment of formal protocols to be implemented in drug administration. Making the ordering and preparation procedure as easy as possible can help to eliminate inefficiencies and misunderstandings that might potentially result in blunders (Martyn et al., 2019). The adoption of an automated drug administration platform will help to expedite this process.
Research has demonstrated that automated solutions are a viable option for preventing medication-related mistakes. They help to improve the efficiency of the whole process, from medication prescription through administration.
Improvement Plan
There is a significant unfavorable relationship between workplace environment and medication errors, according to the research. The frequency of medication mistakes is reduced when nurses’ working environment is improved (Joolaee et al., 2016). Among the issues addressed in the study findings is the issue of fatigued nurses who are at a greater risk of making medication mistakes. Because of this, it is necessary to enhance environmental variables and workplace settings in order to minimize medication mistakes and provide better clinical care.
Improved work contexts must include improved communication amongst workers as well as the provision of them with the required knowledge. Toivo et al. (2019) point out that interdisciplinary teamwork improves the chances of minimizing medication mistakes because it guarantees that every team member has defined tasks and responsibilities, and everybody appreciates the participation of each team member. Our healthcare organization’s collaborative approach between physicians, nurses, and pharmacists will guarantee that all of the client’s requirements and goals are taken into account while performing the different tasks, which may include ordering and preparing medications, as well as organizing and administering them. This will guarantee that environmental variables and human error do not cause inaccuracies and that professionals can utilize the system in a satisfactory manner. Once every two weeks, after two pieces of training, an analysis of the achievements should be carried out when a total of four weeks has passed. Among the outcomes to be evaluated are pharmacists’ involvement and commitment, the number of errors avoided as a consequence of using the system, and the productive and constructive communication between nursing staff and pharmacists.
Organizational Resources
It is critical to incorporate medical systems, executives, and a pleasant organizational climate in order to guarantee that the recommendations are implemented (Cooperberg, 2017). In addition, the healthcare professionals’ involvement in policy formulation and execution is critical to the success of these efforts. The organization, on the other hand, will need the investment of resources such as a sophisticated system that will guarantee efficacy. Medication prescribing and administration courses for nurses and other healthcare workers, as well as cooperation and interaction with pharmacists, will be carried out by third-party entities.
Conclusion
Medication errors are the most common risk factor for adverse outcomes in the hospital setting. Studies indicate that medication errors are a significant health system issue and impact patients’ health and outcomes directly. According to the findings of the given scenario, medication errors are linked to low pharmacist involvement, communication breakdown, an inefficient system, and preoccupied nurses. A reduction in the likelihood of these kinds of errors occurring in healthcare institutions is anticipated to be achieved via an improved working environment, interdisciplinary partnership, and frequent training.

References
Breuker, C., Macioce, V., Mura, T., Audurier, Y., Boegner, C., Jalabert, A., … & Sultan, A. (2017). Medication errors at hospital admission and discharge in type 1 and 2 diabetes. Diabetic Medicine, 34(12), 1742-1746.
Cooperberg, M. R., Fang, R., Schlossberg, S., Wolf, J. S., & Clemens, J. Q. (2017). The AUA Quality Registry: engaging stakeholders to improve the quality of care for patients with prostate cancer. Urology practice, 4(1), 30-35.
Joolaee, S., Shali, M., Hooshmand, A., Rahimi, S., & Haghani, H. (2016). The relationship between medication errors and nurses’ work environment. Medical-Surgical Nursing Journal, 4(4), 27-34.
Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviours beyond the five-rights. Nurse education in practice, 37, 109-114.
Toivo, T., Airaksinen, M., Dimitrov, M., Savela, E., Pelkonen, K., Kiuru, V., … & Puustinen, J. (2019). Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial. BMC geriatrics, 19(1), 332.

Question
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.