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.
Root Cause of Administration Errors
In an oncology clinic of a local healthcare facility, a sentinel event involving medication administration to a patient on chemotherapy was reported. The root cause analysis of the incident was instigated when a female patient aged 45 with breast cancer and on a paclitaxel regimen fell unconscious during chemotherapy. This was detected by the attending nurse. It was found that the drug was administered at a faster infusion rate than the recommended rate. The patient fell unconscious 30 minutes after the initiation of an infusion of the drug paclitaxel.
Analysis of the event revealed that the attending nurse committed an error while administering the medication to the patient and during the administration of pre-chemotherapy medications. She had misread instructions on administering the drug to that specific patient. Paclitaxel can be administered safely by 1-2-hour infusions (Ferrigno et al., 2021). In this specific case, the drug was supposed to run for two hours due to the patient’s vitals and attributes. In the above case, the attending nurse had set the infusion rate at 60 minutes. The nurse had also omitted a corticosteroid dose during pre-chemo.
Most chemotherapeutic drugs are administered sequentially. Premeds with a corticosteroid, an antihistamine, and an antacid precede the chemotherapeutic agent. This sequential administration is important since these drugs have narrow therapeutic indices, and adverse events are often apparent. Premeds and post-meds minimize these adverse effects and promote safety for the patients. In the case above, the nurse was found to have omitted an important premed applicable to paclitaxel use. Additionally, the nurse had committed an error while administering this medication.
Further investigations revealed several issues that may have contributed to the incidence. The nurse had committed an administration error by infusing the drug at the wrong infusion rate. The nurse was found to be experiencing burnout and accustomed to long shifts. She had just completed an 18-hour shift and was called upon to cover for another nurse who had had an emergency and could not report. Her poor mentation may be attributed to fatigue. Report findings also revealed a communication lapse between the pharmacist and the nurse. The pharmacists did not indicate the infusion rate for this specific patient. Communication between the pharmacist and the nurse plays a role in abating medication administration errors. This is because pharmacists have a vast knowledge of the pharmacokinetic properties of various chemotherapeutics agents. In this instance, the presence of pharmacists may have modified the trajectory of the outcomes. All these factors may have contributed to this sentinel event.
Application of Evidence-Based Strategies
Reports on etiologies of various administration errors have always pointed fingers at systemic issues as potential causes of administration errors. Healthcare systems and providers have been implicated in a majority of sentinel events in healthcare related to medication administration. Administration errors such as the wrong rate of administering intravenous medications, wrong route of administration, and administering medications to the wrong patient have been reported in various healthcare settings.
Several strategies can be used to reduce medication administrative issues. Electronic medical record systems and collaboration with pharmacists can help minimize administration errors (Mutair et al., 2021). Electronic medical records systems capture patient information and make it available to other caregivers. Nurses can use this information in making clinical decisions on the appropriateness of the medications and doses to be applied to the patient. Patient attributes that influence dosing and choice of medications that are captured by these systems include the patient’s vitals, other medications they are taking, and any comorbidities. This information is vital in medication administration. Involving pharmacists in medication administration can also help in minimizing errors. Pharmacists can provide accurate information on drug administration that may prevent medication errors. Nurse scheduling and staffing may also minimize errors attributable to nursing practice. Nurse scheduling and staffing reduce the workload on nurses and, therefore, enable them to operate optimally.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The improvement plan applicable in this case scenario utilizes two approaches: the first approach is to increase the effectiveness of nursing interventions in medication administration. This can be achieved by equipping nurses with basic education on drugs, such as pharmacokinetic parameters. Nursing staffing a