Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example

Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example

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

This situation is a typical medication error that is common in clinical settings. Medication errors are caused by different elements or more than one practitioner. In this case, several latent errors contributed to the patient’s harm.  Root cause analysis (RCA) is a structured approach to ascertaining the causal factors of medical errors and adverse events to define precautionary measures (Charles et al., 2016). RCA personnel assesses system factors contributing to or causing medication errors and adverse events other than human errors. The RCA’s ultimate goal is to determine what went wrong, why such errors happen, and how to keep it from recurring.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

The RCA of this risky medication error in which the nurse administered the wrong dosage shows additional flaws in the nursing setting contributing to the adverse patient outcome. Therefore, the RCA is appropriate for this situation because it safeguards patients by characterizing and modifying risk factors in the healthcare system that may bring injury. (Charles et al., 2016). In this case, the RCA team will identify the human and system-related factors that contribute to the nurse’s actions, jeopardizing the patient’s safety.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

For instance, the RCA will uncover the following error (1) the mishap in the hospital’s computerized prescriber order entry (CPOE). (2) The failure of the bedside nurse to check the comment made by the pharmacist on the electronic medication administration record (eMAR). (3) The nurse’s ignorance of the pharmacist’s patient-specific labels and use of the calibrated syringe. Through these outcomes, the hospital can put measures such as an update of computerized prescriber order entry, appropriate communication channels between medical personnel, and cautions against the ignorance of colleague’s comments. Moreover, this would make it difficult for clinical personnel to make errors, detect, and correct errors before they occur.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

The impact of RCA, FMEA, and PDSA on the quality and safety of patient care.

RCA assesses and highlights the causes and contributing factors to an adverse clinical situation. The hospital can take actions, which would prevent future recurrence (Martin-Delgado, Martínez-García, Aranaz, Valencia-Martín, & Mira, 2020). Besides, the hospital can measure planned interventions to determine, thereby guiding an in-depth understanding of the clinical mishaps, appraisal of nursing practices, and quality aspect, thus, ensuring quality and safe patient care.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

Like RCA, the Failure Mode and Effects Analysis (FMEA) is a healthcare tool used to reduce error and improve healthcare processes, thus, improving healthcare quality and safety.  The healthcare FMEA process identifies potential mishaps and their causes to guide preventive measures (Liu, Zhang, Ping, & Wang, 2020). Besides, healthcare FMEA provides guidelines on improving current clinical services, leading to enhance patient safety and quality care services. Lastly, RCA can guide clinical personnel to avoid focusing on specific sources of error but a systematic approach to medication errors. This would allow correction of underlying system failures, leading to improved quality of care services and patient safety.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

PDSA (Plan-Do-Study-Act) is a practical problem-solving healthcare model established to improve clinical processes through a guided change of defective practices. Coury et al. (2017) argue that PDSA is a crucial model for quality improvement initiatives in healthcare systems. This is because its methods ensure the quality and consistency of proposed changes, adapt the new processes to the desired context, and minimize risks of harm and unintended consequences to patients (Knudsen et al., 2019). Therefore, understanding PDSA functions can facilitate care quality and patient safety initiatives, leading to an evidence-based intervention in daily clinical processes.  ( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)

References

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 1-5.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example) 10.1186/s13037-016-0107-8

Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., … & Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC health services research, 17(1), 1-10. 10.1186/s12913-017-2364-3

Knudsen, S. V., Laursen, H. V. B., Johnsen, S. P., Bartels, P. D., Ehlers, L. H., & Mainz, J. (2019). Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC health services research, 19(1), 1-10. https://doi.org/10.1186/s12913-019-4482-6

Liu, H. C., Zhang, L. J., Ping, Y. J., & Wang, L. (2020). Failure mode and effects analysis for proactive healthcare risk evaluation: a systematic literature review. Journal of evaluation in clinical practice, 26(4), 1320-1337.( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example) 10.1111/jep.13317

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review. Medical Principles and Practice, 29(6), 524-531. ( Multifactorial Medication Mishap RCA Comprehensive Nursing Paper Example)https://doi.org/10.1159/000508677