Root-Cause Analysis and Safety Improvement Plan
In the previous assessment, medication administration errors (MAEs) were linked to human and organizational factors. Regardless of the cause of MAEs and magnitude, their occurrence threatens care quality and patient safety directly or indirectly. However, without a systematic approach to the problem, the underlying root factors of medication administration errors may be left unresolved. A root-cause analysis (RCA) problem analysis process helps identify the root causes of issues to develop suitable solutions. This paper leverages the RCA method to analyze the root causes of MAEs in identified cases within a select hospital setting. It also presents evidence-based strategies applicable to address the causes of MAEs identified. It proposes an evidence-based improvement plan that can utilize the available organizational resources to reduce and prevent the occurrence of medication administration errors.
Analysis of the Root Cause
Medication administration errors are the primary and most common medical errors contributing to preventable patient harm. Medication administration mistakes can also result in adverse drug effects (ADEs), significantly impacting patients’ health and quality of life while also increasing the burden on the healthcare system. MAEs vary in magnitude and impact on patient safety and quality of care. Some medication administration errors may not cause harm to the patient, while others lead to ADEs and risk extreme outcomes, including death.
A root cause analysis was conducted by experts from the risk management department on 16 actual errors and 22 near-miss cases reported during the medication administration within the in-patient care settings across all departments in the hospital. The RCA aimed to understand the causes and underlying factors that contributed to errors and near-miss events in the in-patient care settings within the hospital. This information was utilized to select evidence-based strategies to improve the safety and quality of the medication administration process within the hospital and determine the resources needed for the improvement plan.
According to the RCA, 70 percent of the cases reported of actual medication administration errors were caused by nurses, while physician assistants caused 10, and 20 percent were related to patient mistakes. Also, 60 percent of the MAEs occurred during the night shift, while 40 percent occurred during the day shift. The MAEs occurring during the night shift had various contributing factors. The RCA identified that the nurses involved in 40 percent of the reported cases reported feeling worn out during the events after serving several patients due to the low number of nurses during the night shift. They also noted that in 20 percent of the cases, there were no pharmacists to consult on the medications provided, while five percent of the dosages entered on the patient bedside files were illegible. The RCA also noted that the names of the medicines to be administered were confusing in eight percent of the cases. Additionally, it was identified that cases involving the wrong dosage, wrong patients, and wrong delivery methods were due to 12 percent wrong dose calculation, seven percent wrong patient indicated, and eight percent confusion over the site shown on the medication.
The RCA also identified similar causes and underlying factors related to the errors occurring during the day shift. Additionally, the RCA noted that 30 percent of errors occurred due to distraction, 28 percent involved stress from high patient volumes during the day, and 12 percent involved patients moving during medication administration. In addition, 30 percent of the cases involved nurse students with limited experience in medication administration. The lack of collaboration between nurses and physician assistants was also identified as a root cause of 80 percent of the reported cases during the day and night shifts. Additionally, 80 percent of the near-miss instances were due to physicians and pharmacists doing ward rounds intervening during the medication administration, while 20 percent were after nurses consulted with other healthcare professionals during the administration process.
Application of Evidence-Based Strategies
Various evidence-based strategies can be applied within hospital settings and beyond to reduce and prevent the occurrence of MAEs. The safety of the medication process can be achieved by employing advanced multi-professional collaboration, improving communication effectiveness, and ensuring adequate skills during medication administration. Further, the safety of the medication process can be improved by implementing a systematic medication process and eliminating distractions from the work environment. Adopting a nursing curriculum that focuses on developing evidence-based competencies equips future nurses wi