Root Cause Analysis and Safety Improvement Plan

 This assignment will examine a medication error, which the Agency for Healthcare Research and Quality (AHRQ, 2019) defines as mistakes within the health care field that happen along the medication pathway, whether during the prescription, order, dispense, or administration of medications to patients. According to the National Coordinating Council for Medication Error Reporting and Prevention(NCCMERP,2021), these medication errors are considered preventable events that can lead to adverse drug events (ADEs), where patients experience some harm due to the error. However, it is considered a sentinel event if the medication error causes substantial damage to the patent, such as temporary or permanent disability or even death(Rodziewicz et al., 2021). Therefore, this assignment will examine a medication error, then undertake aroot cause analysis (RCA) to identify the potential underlying factors that played a part in the error. Evidence-based strategies to address the cause of the error will then be evaluated, developing an improvement plan based upon these best practices to help prevent this error from happening again in the future. Finally, existing organizational resources to implement this improvement plan will be examined. Analysis of the Root Cause The Institute for Healthcare Improvement (IHI, 2016) describes six steps used in the RCA process, including outlining the sentinel event and what went wrong, while then explaining what should have happened for it to be considered the “right” process. Another step is to ascertain all probable causes that led to the error, developing causal statements which can then be employed to find appropriate actions that can be taken to prevent the error from happening again (IHI, 2016). The medication error comes from a case study regarding a 23-year-old woman who presented to the emergency department (ED) with flu-like symptoms, complaining of generalized

3 body ache; she had a fever of 102.6, while a CT scan showed abnormal results, with blood ℉cultures identifying Streptococcus Pneumoniae(Nurses Service Organization [NSO], n.d.). Antibiotics were ordered and she seemed to be improving, although her attending noted abnormal blood chemistry, with a low potassium level that persisted even with 30mEq of potassium infused at 80 milliliters per hour after two days; therefore, two doses of 40 mEq of potassium were ordered to infuse over a four-hour period (NSO, n.d.). However, the intensive care unit (ICU) nurse instead administered two intravenous potassium doses of 20 mEq over about one hour; the nurse noted the patient’s heart rate began to increase throughout the day, although her blood pressure remained stable, and she was eventually transferred to the telemetry unit, where the patient went into cardiac arrest and died (NSO, n.d.)