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Root-Cause Analysis and Improvement Plan

Root-cause analysis (RCA) is an approach that evolved in the medical field and is used to explore the direct and indirect contributing variables for a preventable adverse event and develop a prevention strategy (Kwok et al., 2020). The most common application of RCA in healthcare is in the analysis of Medication Administration Errors (MAEs), which contribute to Adverse Drug Events (ADE). ADE has adverse patient implications, ranging from insignificant negative outcomes to potentially fatal situations (Singh et al., 2023). MAEs resulted in a patient safety issue at the Vila Health Hospital. This study will investigate the root cause of the MAE incident, taking into account the factors that contributed to the problem. Furthermore, an evidence-based safety improvement plan will be developed based on the organization’s available resources to avoid such problems. 

Root-cause analysis of medication administration errors

One of the biggest causes of preventable patient damage in healthcare systems is inappropriate drug practices. The majority of these errors occur during the process of administration of drugs. Nurses are mainly accountable for MAEs (Wondmieneh et al., 2020). Lack of collaboration and records, a lack of medication interaction understanding, and inadequate instruction for patients result in MAEs that cause ADE (Guncag et al., 2021). By completing a comprehensive RCA, organizations can determine the sources of mistakes and design focused measures to avoid adverse events. A 52-year-old, Mr. Joseph, experienced adverse events due to MAEs. He was the patient of cardiac myopathy.

During his hospital stay, the nurse misunderstood his handwritten medication prescription and gave him the wrong medicine, resulting in severe ADE, including increased cardiac rate and shortness of breath. It happens due to the injurious reaction of the wrong medicine with other drugs. The medication administration mistake committed by the nurse was an underlying concern. Poor standard of care and uncertain practices can result in significant death and disability in patients (Vaismoradi et al., 2020). To prevent repeated occurrences of severe drug reactions due to MAEs, it is critical to develop compatible guidelines for medication dispensing and highlight the importance of administering drug education (Vaismoradi et al., 2020). As a result, it is critical to recognize the elements contributing to the issue and develop an immediate safety improvement plan to address them.

Elements Contributed to Safety Issues

Assessing the primary cause of the patient protection concern, mainly Ms. Joseph’s MAE incident indicates various contributing variables relating to drug administration in the healthcare system.

• Inappropriate Medication Reconciliation (MR) and evaluation methods, such as the absence of complete drug records and accurate prescription histories, result in MAEs and harm the well-being of patients (Millichamp & Johnston, 2020).
• During nursing training, nurses acquire the five rights of administering medicines, which include the proper patient, prescription medicines, dosage, mode of delivery, and time. However, there are instances where nurses fail to adhere to this standard guideline, resulting in MAEs (Martyn et al., 2019). According to research, 38.6% of pharmaceutical mistakes were attributed to incorrect time management, while 27.5% were attributed to incorrect evaluation and prescription to the incorrect patient (Tsegaye et al., 2020).

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

• The absence of defined standards for pharmaceutical prescribing, as well as clear recommendations and decision support systems, leads to dependence on human knowledge, which increases the risk of MAEs and adverse events (Alshahrani et al., 2021).
• Continuing professional education (CPD) is critical for nurses to promote and upgrade their expertise and abilities based on recent developments (Hakvoort et al., 2022). It is reported that improper or lack of training of nurses leads to the MAEs. According to research, 78.7% of MAEs are caused by inadequate education (Tsegaye et al., 2020). This evidence demonstrates that nurses with a limited understanding of medications can make mistakes during medication administration without identifying side effects that can compromise patient safety (Hakvoort et al., 2022).

Application of Evidence-Based Strategies

Evidence-based and standard interventions can tackle the incidents due to MAEs and the fundamental reasons indic