NURS FPX 4020 Assessment 2: Root-Cause Analysis and Safety Improvement Plan

NURS FPX 4020 Assessment 2: Root-Cause Analysis and Safety Improvement Plan

 

 

Root-Cause Analysis

Root cause analysis (RCA) is an issue and problem analysis methodical process, which is used in identifying potential causes related to adverse events, sentinel, near misses, and conflict in the workplace (Kellogg et al., 2016). The purpose of this paper is to apply RCT to the case study to apply EBP strategies to address sentinel events, develop a safety improvement plan, and identify organizational resources that can aid in improving the safety improvement plans. A case study related to medication error in health care, which led to sentinel events of allergic reaction and blame culture was selected for analysis. The allergic reaction included difficulty in breathing and severe dizziness. In the selected scenario or case study, the team was made up of a staff nurse, a risk manager, a pharmacy technician, and a medication dispenser. The risk manager was the mediator or the leader of the interdisciplinary team, who has the role of facilitating and directing the RCA process to solve the conflict and find the causes (Kellogg et al., 2016).

Analysis of the Root Cause

In the case study, a patient was admitted to the hospital to get treatment for acute diverticulitis. A prescription order of 50 mg Tramadol hydrochloride for every 6-hour PRN pain was sent to the pharmacist. However, it was not administered for the past 8 hours and the patient was asking for the pain medication. The nurse could not administer the medication as the bar-code scanner was not working. However, the nurse used an internal entry number in the computer to assess whether the correct medication was sent. The entry showed that the medication was 325mg, but the medication package said 50mg. The staff nurse followed the hospital’s guidelines to scan the medication barcode, check the medication in the system, and contacted the pharmacist to report the error.

The pharmacist informed the nurse that there is one digit difference between Ultracet (325mg) and Ultram (50mg) and asked the nurse to administer the medicine and alleged that she might have typed the number wrong. As a result, the nurse administered the medication as the patient was in pain and this led to difficulty in breathing and dizziness. Later, the nurse checked the patient’s record and found that he was allergic to acetaminophen. After that, treatment was provided to the patient and the nurse logged a medication incident report. However, the pharmacy technician and nurse manager failed to take the medication error responsibility and this resulted in a blame culture. As the nurse detected both the error and the allergic reaction, she was at the center of RCA.

As the RCA team helps in analyzing the issue and finding the root cause of the problem, it included a risk manager, a full-time RN in the unit, and a full-time pharmacy technician from the pharmacy. The Risk manager helps in identifying different threats to patient safety. The full-time RN will provide expertise on MAP and also explains the process behind barcode medication administration. The pharmacy technician helps in explaining the process behind filling medication dispensing machines (Kellogg et al., 2016).

What was supposed to occur?

The nurse used a flowchart to analyze whether the patient needs medication or not and checked the med box, reviewed medicine in the system, and reported the medication error. The pharmacist did respond to the issue and highlighted the key difference between the two medications, but he blamed the nurse and ignore the possible medication error and its adverse effects instead of verifying the medicine. This is a violation of the ethics of nursing and medicine (Tariq et al., 2021). Also, the nurse administers the medication despite knowing the error. Instead of just suggesting to the staff nurse that she might have entered the wrong IEN, the technician should have informed the staff nurse to request the correct medicine. Also, the staff nurse could have clearly mentioned that IEN is correct. She should have escalated the issue to the nurse manager instead of administering the medication (Manias, 2018). Also, she did not review the patient’s record as he was allergic to the medicine.

The issue started at the beginning as the first root cause was when the pharmacist dispatched the wrong medicine with dosage (Tariq et al., 2021). Further, the second root cause was the nurse delayed medication administration even though she was supposed to admin

Order a similar paper

Get the results you need