Scenario For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan: The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns. The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration. Instructions
Root-Cause Analysis and Safety Improvement Plan
A majority of adverse drug events (ADEs) are due to errors in medication administration. ADEs are preventable; however, they remain an issue of concern in nursing and other care settings. Multiple factors can contribute to a single or multiple ADEs. A comprehensive analysis of the ADEs is required to determine their root causes and provide long-term solutions and interventions. This paper will apply the root-cause analysis (RCA) technique to analyze the root causes of an ADE issue related to a diabetic patient. It will also apply evidence-based strategies to address the ADEs as a safety issue in medication administration. In addition, it will also describe a safety improvement plan designed to prevent the reoccurrence of the safety issue and other events that impact patient safety within the hospital and available organizational resources to support the plan.
Analysis of the Root Cause
ADEs are unwanted, unexpected, or unintended outcomes after medication administration. ADEs result from an error occurring during the medication administration process. ADEs greatly compromise the safety of the patient and care quality and increase the risks of morbidity and mortality with significant financial implications (Bankes et al., 2020). ADEs can also significantly impact the patient’s quality of life and their experiences during the period of provision of care. The impact of ADEs varies from those that are intercepted before they occur to those that are life-threatening and cause a loss of life. The following is an incident for which the root cause analysis is being conducted.
Mrs. Sara is a 54-year-old Type 2 diabetic patient who had been admitted to the facility for the last three weeks but was discharged a week ago. She had been using glibenclamide during her hospital stay to manage her blood sugar, which had gone too high to life-threatening levels. She could not exercise regularly and noted that she could not manage to follow the diet plan that had been developed for her. Three days before her discharge, the physician noted that she had a case of hypoglycemia and changed her prescription to gliclazide. The new gliclazide regimen helped manage her blood sugar and reduced the risk of hypoglycemia. The physician confirmed that she continues taking gliclazide as she could not exercise and maintain the expected diet. A week after her discharge, she was brought to the hospital emergency care department with a case of severe hypoglycemia, general body weakness, nausea, and tremors, and she recorded two seizures in the last two days. The severe hypoglycemia and the accompanying symptoms were concluded as adverse drug events in relation to the medication she was taking.
After she was stabilized, a quick meeting involving the nurses and physicians on duty during the discharge of Mrs. Sara was called to help determine the causes of her severe hypoglycemia and the other symptoms she manifested. A root cause analysis (RCA) was ordered to investigate the causes of her condition and help develop interventions to support her care and reduce the risk of hypokinemia from becoming life-threatening.
The RCA identified a number of factors that had contributed to the ADE affecting Mrs. Sara. Firstly, the RCA found that, although the physician had prescribed gliclazide as a replacement for the glibenclamide, the patient still took both medications at once. This mistake was linked to the failure of the physician to indicate that the patient was no longer supposed to use glibenclamide. This miscommunication between the physician, the nurses, and the discharging team led to the patient getting glibenclamide and gliclazide. Further, there was no review of the discharge sheet during the release of the patient by either the discharge officer or the pharmacist during the dispensation of both medicines. Additionally, it was established that Mrs. Sara had used glibenclamide for a prolonged period, even before she was admitted to the facility. Glibenclamide has been found to have excellent glycemic control properties; however, it risks the development of severe hypoglycemia under prolonged use (Huang et al., 2019). Therefore, the RCA results can be interpreted to show the root causes, including poor interdisciplinary team communication, prolonged use of glibenclamide, and some aspects of negligence.
Application of Evidence-Based Strategies
The ADE affecting Mrs. Sara can be addressed through the application of evidence-based and best-practice strategies. The first aspect is to address safety by improving the safety of the process of drug treatment. Improving the medication treatment process means improving the competency of nurses and other healthcare professionals in the processes related to medication prescription and administration. The medication tr