Root Cause Analysis and Safety Improvement Plan

Root Cause Analysis and Safety Improvement Plan

Root-cause analysis is a systematic process used to identify the root causes of events or problems and find an approach to respond to them (Washington State Department of Enterprise Services, 2020). It is based on the notion that effective management involves more than simply putting out fires for any problems that arise and actually finding ways to prevent them. This paper will focus on the root-cause analysis of medication errors in intensive care units and make use of evidence-based and best-practice strategies to address the issue. An improvement plan will also be suggested together with the organizational resources that must be leveraged to improve the plan.

Patient safety is considered a priority in most healthcare organizations as it ensures high quality of care. Errors in healthcare arise from an unintended action caused by some failure or action while providing care. Any member of the healthcare team can commit that error. In most cases, when medical errors occur, it is common for the professional to face disciplinary actions, losing jobs, humiliation, and legal repercussions. Rodziewicz and Hipskind (2018) note that healthcare professionals experience intense psychological effects like depression, anger, inadequacy, and reduced clinical confidence due to perceived errors and the punishment linked to the errors results in a reluctance to report errors. Addressing the root causes of medication errors and finding proper solutions is of great importance.

Root Cause Analysis in Intensive Care Units

In the Intensive Care Unit, patients experience about 1.7 errors on average in a day, and approximately all of them suffer a probable life-threatening error at some point in their stay, and medication errors are responsible for about 78 percent of severe medical errors in the ICU (Farzi et al., 2017). More drugs are usually administered to patients in the ICU compared to other units, and since patients are usually unconscious or drowsy, they are unable to monitor and report the side effects of the drugs. Medication errors result in increased length of stay in hospital, disabilities, and even death.

A convergence of various factors results in medication errors in the ICU. Some of the commonly identified root causes are incorrect prescription by physicians, lack of pharmaceutical knowledge of the healthcare team, unsafe administration of drugs by nurses, and weak professional collaboration as well as poor communication (Farzi et al., 2017). Inadequate staffing, as well as human factors like poor environmental conditions and fatigue, are also identified as root cause of medication errors in the ICU (Always Culture, 2020; Abd Elgwad et al., 2020).

A root-cause analysis was performed on 16 ICUs of 7 different educational hospitals. The participants included clinical pharmacists, nurses, and physicians with 1 or more years of ICU experience. The aim of the study was to identify the causes behind the high number of medication errors reported in the ICUs (Farzi et al., 2018). The ICU is a section that requires interprofessional care, and patient safety can be enhanced through commitment and participation among members. However, it was identified that this interprofessional team was among the major causes of medication errors in the ICU due to such things as poor communication and misinformation. The result of medication errors in most of the hospitals was increased hospital stay as well as deaths. In the study, some participants reported that such human errors as a physician’s inattention to the medication, particularly antibiotics led to patients receiving more drugs than they should (Farzi et al., 2018). In relation to lack of professional collaboration and communication, some nurses reported that the physician’s handwriting was illegible, and some nurses failed to seek clarification for fear of being termed reckless and the physician getting angry. Research shows that interprofessional education can enhance interprofessional communication and collaboration and hence reduce medication errors in the ICU and improve patient safety (Irajpour et al., 2019). Through proper communication channels, this mistake could have been avoided.

Some cases involved physicians’ inadequate medication knowledge, resulting in medication errors like wrong medication orders and medication interactions. Some of the nurses also reported being fatigued and drowsy, and interruptions and talking could disrupt their administration of medicine, causing them to mix up patients’ medication. Furthermore, some nurses complained of heavy workloads and stress, which caused unintentional omissions or wrong medication. Since patients in the ICUs are gravely ill, having one nurse caring for more than 3 seriously ill patients is too much, as stated by some nurses (Farzi et al., 2018). The surgical and ICU units are often understaffed. Research shows that sufficient staffing can mitigate medication errors (Cloete, 2015; Härkänen et al., 2020). Among other things, proper staffing could minimize fatigue, boost work morale, and increase vigilance during medication administration.

Some of the hospital infrastructures that contributed to the medication errors in the ICU include poor lighting and disorderly shelves because of the large number of medicine. Farzi et al. (2018) note that the ICUs have poor lighting and they need to rely on overhead lights, but sometimes, they fail to switch on the light to avoid disturbing the patient’s comfort, and this causes them to pick the wrong drugs from the highly staffed shelves.

Application of Evidence-Based Strategies

Participants reported incomplete medication orders, including failure to write the route or drug dosage and medication orders, which resulted in medication errors. Computerized prescription order entry is likely to improve communication between the healthcare team to lessen adverse drug events, and medication errors (Roumeliotis et al., 2019) since the manual prescription is among the main medication error causes (Mieiro et al., 2019). Proper implementation and knowledge of computerized prescriptions can help minimize medication errors.

Interruptions or talking when administering medication or conducting pharmaceutical calculations were among the causes of erroneous drug administration. Interruption tends to increase the probability of medication errors by 12.5 percent, and if a nurse administers a drug without interruption, the likelihood of errors lessens to 2.3 percent (Farzi et al., 2018). Another cited factor was inadequate pharmaceutical knowledge, and Farzi et al. (2018) recommend education concerning medication and drug safety as an important strategy to lessen medication errors. Lastly, insufficient collaboration among the healthcare professionals as well as lack of communication with the patients, can result in medication duplication and intensification or weakening of the medications administered to patients. Poor communication is possibly the greatest cause of medication errors in ICUs. Interprofessional collaboration and communication are necessary to enhance efficient and effective care and also prevent medication errors (Irajpour et al., 2019). Patients in the ICU are dependent on the collective skills and expertise of the critical care team since most of them are “voiceless,” therefore, Kendall-Gallagher et al. (2017) recommend networking, coordination, collaboration, and teamwork with strong and effective communication as well as collective action to improve patient safety and outcomes.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan is based on three strategies, namely: interventions to lessen distractions, using appropriate technologies for drug administration, and training on effective interprofessional collaboration. Distractions can be lessened by using clerk triage of pages and phone calls during peak medication times (Zakria & Mohamed, 2017). Furthermore, healthcare facilities can implement a sterile cockpit rule, which implies the elimination of distractions during medication to avoid medication errors. This is a strategy that is borrowed from the airline industry and is meant to maintain safety in the cockpit section by avoiding nonessential conversations and activities during the flight’s critical phase (Chu, 2016). This rule is linked with a 42.78 percent reduction in medication errors and can be implemented by having a “quiet zone” or “do not disturb” sign in medication preparation regions (Chu, 2016). However, educating the critical care team on the importance of avoiding distractions such as keeping their phones away can also be helpful. The cockpit rule should be implemented within a span of 1 month to lessen distractions during medication calculation and administration.

Appropriate technology in monitoring, administering, and storing medication can increase medication safety. Some of the technologies that can be used include medication storage (radiofrequency identifiers), computerized decision support systems which caution high-risk medication, improved wristbands for patient identification, and surveillance systems to enable quick recognition of adverse events (Klingner & Prasad, 2016). Making use of computerized prescriptions has also been identified as an effective way of lessening medication errors. Implementation of these technologies should be done within a month and should be an ongoing process with updates to ensure that it is current with current changes.

Ineffective interprofessional collaboration and communication have been cited among the major causes of medication errors in the ICU. Providing continuous education and training through seminars and role-plays of collaboration can enhance patient safety (Patima, 2020). Such factors as effective communication, respect for the skills and expertise of individual members, autonomy, shared decision-making, and accountability should be promoted to enhance team cohesion.

The organizational resources that need to be leveraged are existing hospital staff and new technologies. It is important to ensure training of the existing staff to ensure that they are well informed and educated in regard to the operation of the technologies employed in drug administration as well as the cockpit rule. New technologies might require hiring expertise from outside to implement them. Even though this might cost a huge amount of money, it will lessen the high cost associated with medication errors in the long run. Lastly, seminars will require a team of experienced professionals either within or outside the organization to train and educate the critical care team on interprofessional collaboration.

Conclusion

Critical care units tend to have the highest number of medication errors, which are usually life-threatening. Most hospitals deal with medication errors through punitive measures that only lessen the confidence of the professionals and could result in reduced quality of care. Finding the root causes of medication errors and eliminating them could go a long way in ensuring patient safety. Poor communication, inadequate pharmaceutical knowledge, understaffing, manual prescription, and distractions during medication are among the main causes of medication errors in ICUs. Some of the evidence-based strategies, like adequate staffing, improving interprofessional collaboration, adequate staffing, coordination, and communication as well as increasing staff pharmaceutical knowledge and calculation, can minimize medication errors. Computerized prescriptions, implementation of the cockpit rule, and training on interprofessional collaboration have been suggested as improvement plans to lessen medication errors.

References

Abd Elgwad, S. I., Abdallah, K. F., & Khalil, A. P. B. (2020). Assessment of Medication Errors among Nurses in the Intensive Care Unit. International Journal of Novel Research in Healthcare and Nursing, 7(3), 309-317.

Always Culture. (2020). The 8 Most Common Root Causes of Medical Errors. Retrieved from https://alwaysculture.com/hcahps/communication-medications/8-most-common-causes-of-medical-errors/

Chu, R. Z. (2016). Simple steps to reduce medication errors. Nursing2020, 46(8), 63-65.

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1), 50-59.

Farzi, S., Irajpour, A., Saghaei, M., & Ravaghi, H. (2017). Causes of medication errors in intensive care units from the perspective of healthcare professionals. Journal of research in pharmacy practice, 6(3), 158.

Härkänen, M., Vehviläinen‐Julkunen, K., Murrells, T., Paananen, J., Franklin, B. D., & Rafferty, A. M. (2020). The contribution of staffing to medication administration errors: A text mining analysis of incident report data. Journal of Nursing Scholarship, 52(1), 113-123.

Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. Journal of education and health promotion, 8.

Kendall-Gallagher, D., Reeves, S., Alexanian, J. A., & Kitto, S. (2017). A nursing perspective of interprofessional work in critical care: Findings from a secondary analysis. Journal of critical care, 38, 20-26.

Klingner, J., & Prasad, S. (2016). Evidence-Based Medication Safety Quality Improvement Programs and Strategies for Critical Access Hospitals. University of Minnesota Rural Health Research Center.

Mieiro, D. B., Oliveira, É. B. C. D., Fonseca, R. E. P. D., Mininel, V. A., Zem-Mascarenhas, S. H., & Machado, R. C. (2019). Strategies to minimize medication errors in emergency units: an integrative review. Revista brasileira de enfermagem, 72, 307-314.

Patima, P. (2020). Determinant Factors of Interprofessional Collaboration in Labuang Baji General Hospital. Medico Legal Update, 20(4), 2117-2120.

Rodziewicz, T. L., & Hipskind, J. E. (2018). Medical error prevention. StatPearls Publishing, Treasure Island.

Roumeliotis, N., Sniderman, J., Adams-Webber, T., Addo, N., Anand, V., Rochon, P., … & Parshuram, C. (2019). Effect of electronic prescribing strategies on medication error and harm in hospital: a systematic review and meta-analysis. Journal of general internal medicine, 34(10), 2210-2223.

Washington State Department of Enterprise Services. (2020). Root Cause Analysis. Retrieved from https://des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysis#:~:text=Root%20cause%20analysis%20(RCA)%20is,a%20way%20to%20prevent%20them.

Zakria, A. M., & Mohamed, S. A. (2017). Safety Intervention Educational Program to Reduce Medication Administration Errors and Interruptions. IOSR Journal of Nursing and Health Science, 6(2), 15-25.

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Root Cause Analysis and Safety Improvement Plan

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in
health care setting of your choice and outline a plan to address the issue.
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in
implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety
Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help
you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and
concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not
graded and demonstrate course engagement.

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course
competencies and assessment criteria:

• Competency 1: Analyze the elements of a successful quality improvement initiative.
  Apply evidence-based and best-practice strategies to address a safety issue or sentinel event
  pertaining to medication administration. ;
  Create a viable, evidence-based safety improvement plan for safe medication administration.
• Competency 2: Analyze factors that lead to patient safety risks.
  Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication
  administration in an organization.
• Competency 3: Identify organizational interventions to promote patient safety.
  Identify existing organizational resources that could be leveraged to improve a safety improvement
  plan for safe medication administration.
• Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that
  supports safe and effective patient care.
• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using
  current APA style.

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations
developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine
the causes of patient safety issues, in solving problems, and in implementing quality improvements.

For this assessment, you may choose from the following options as the subject of root-cause analysis and safety
improvement plan:
The specific safety concern identified in your previous assessment pertaining to medication administration
safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue
or concern with medication administration.

Instructions

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a
specific safety concerns in a healthcare setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and
professional best practices as well as the existing resources at your chosen healthcare setting to provide a rationale
for your plan.

Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help you to stay organized and concise.
This will guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring
guide. Please study the scoring guide carefully so you understand; what is needed for a distinguished score.

• Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication
  administration in an organization.
• Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to
  medication administration.
• Create a feasible, evidence-based safety improvement plan for safe medication administration.
• Identify organizational resources that could be leveraged to improve your plan for safe medication
  administration.
• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using
  current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the
scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication
administration.
Assessment 2; Example [PDF].

Additional Requirements

• Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4-6
  page root cause analysis and safety improvement plan pertaining to medication administration.
• Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your
  findings and considerations. Resources should be no more than 5 years old.
• APA formatting: Format references and citations according to current APA style.
• Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you
  complete the final Capstone course.