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Multifactorial Medication Mishap RCA

Multifactorial Medication Mishap RCA

A root cause analysis is appropriate in this case study because the cause of a drug mistake is never the responsibility of a single person who works within the large and complicated cycle of drug use. Mistakes in the drug are mostly the result of a deterioration of at least 1 of the 10 main factors influencing drug use. Such major elements are mutually reinforcing the drug-use process: prescribing drugs, order preparation, dispensing, administration, and monitoring (Schafer, 2012, para. 8). The pharmacist collected, labeled, and presented the drug and a calibrated syringe to the bedside nurse to explain this was a higher dose prescription for added protection. The nurse must double-check the medication with another practitioner before administering the medication. There would have been procedures to protect if the drug needed to be manually double-checked. I will address the effect on the quality and safety of patient care by the use of resources such as RCA, FMEA, and PDSA.

RCA factors are one of the most commonly used methods for enhancing patient health. Ineffectiveness of the RCA mechanism including inadequate approaches in educational strategies and implementation of current policies, failure to integrate data through agencies, and failure to combine individual factors design and safety engineering concepts into error detection and enhancement efforts. Double checking ensures that a greater percentage of mistakes are reported to the prescribing, dispensing, and administration of the product. Failure to supply this medication in an individual dose of the syringe would have prevented the error from occurring.

FMEA is a time-consuming procedure requiring a multidisciplinary team with a strong understanding of the mechanism being studied. FMEA is only helping to understand the risks of a project failing; it is not eliminating them; it is worth taking further steps to develop and implement action plans. Practical implications FMEA is an important proactive risk management strategy and an emerging process that can be in stages. The orientation which can ensure danger is in the provision of awareness and facts. The company can often easily implement draft policies and laws and also depend on human diligence (Subriadi et al., 2020, para. 1). Added a note to both the record of electronic medication administration and the patient-specific label indicating the amount to be issued. The pharmacist collected, labeled, and presented the drug and a calibrated syringe to the bedside nurse to explain this was a higher-dose prescription for added protection.

Plan, Do, Study, Act (PDSA) cycles provide a framework for the adaptive testing of changes to improve quality systems (Rostami et al., 2017, para. 21). The six rights of medication administration could have also prevented this error. After administering the drug, the nurse went on break instead of assessing the patient during and after administering the medication and documenting the effects.

Any more of these tools’ chief impact is that they increase liability among remedial staff members. Normally, expanded rates of liability preserve the possibility of restoring the protection of supportive custody within the healthcare environment, whereby each of these instruments is therapeutic in recognizing problems with the way treatment is delivered. With that in mind, inspection practitioners are warning as a device like RCA, FMEA, and PDSA can reveal the source and origin of a supply within the healthcare system that is a gift for eternity. In this way, these devices intensify the flattening of liability in the medical professional’s company and this raises the usual demand for patient care to be seen.


AHRQ (2019). Root Cause Analysis. Retrieved from: analysis

Rostami, P., Power, M., Harrison, A., et al. (2017). Learning from the design, development, and implementation of the Medication Safety Thermometer. Retrieved from:

Schafer J. J. (2012). A root cause analysis project in a medication safety course. American Journal of pharmaceutical education. Retrieved from: (para. 8).

Subriadi, A. P., & Najwa, N. F. (2020). The consistency analysis of failure mode and effect analysis (FMEA) in information technology risk assessment. Heliyon, 6(1), e03161. (para. 1).


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Review the Multifactorial Medication Mishap case study and the commentary that follows.

Respond to the following in a minimum of 175 words:

Multifactorial Medication Mishap RCA

Multifactorial Medication Mishap RCA

Explain why a root cause analysis was appropriate for this situation.

Analyze the impact of using tools such as RCA, FMEA, and PDSA on the quality and safety of patient care.

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