Capella 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan NURS-FPX 4020 Improving Quality of Care and Patient Safety ​​​​​​​Root-Cause Analysis and Safety Improvement Plan

Following the RCA, we will present a robust safety improvement plan anchored in evidence-based methodologies and best practices tailored to rectify and prevent such discrepancies in the future. This discourse aims to give readers an exhaustive comprehension of the incident, its causative elements, and the proposed remedial measures.

Analysis of the Root Cause

At City Hospital’s cardiology ward, an unsettling medication error brought to light significant systemic vulnerabilities. Mrs. Smith, a 68-year-old patient, was inadvertently given ‘metformin,’ a medication for diabetes, instead of her prescribed ‘metoprolol,’ a beta-blocker tailored for her heart condition. This error only surfaced the following morning when a more vigilant or perhaps familiar nurse spotted the discrepancy during her routine medication rounds.

Addressing the immediate implications, Mrs. Smith, being the primary subject of this mistake, experienced unnecessary distress. The strain of being diagnosed with hypertension and heart failure was intensified when she was erroneously given a medication unrelated to her medical profile. This incident points to a cascade of issues, ranging from individual oversight to broader systemic gaps.

Diving deeper into the sequence of events, Mrs. Smith’s medication regimen was clear and explicitly laid out. As a patient diagnosed with hypertension and heart failure, her medical profile necessitated the administration of ‘metoprolol.’ However, a couple of factors converged, leading to the oversight. First, the nurse’s misinterpretation of the prescription within the EHR system made her confuse ‘metoprolol’ with ‘metformin.’ The healthcare setting, particularly the bustling cardiology ward, presented multiple challenges.

Capella 4020 Assessment 2

The noise, potential distractions, or the stress of managing several patients simultaneously may have contributed to the lapse. Such environments demand robust systems to preempt potential errors. Mrs. Smith’s lack of a double-check mechanism for medication dispensation became a glaring omission. The pivotal role of such systems is underlined by healthcare governing bodies, such as The Joint Commission (Rodziewicz et al., 2023). Had such a protocol been followed diligently, the medication error concerning Mrs. Smith could have been averted. Delving into specific root causes:

• Equipment or Resource Factors: Though designed to streamline and improve patient care, the EHR system had shortcomings. A more proactive system would have flagged the discrepancy between Mrs. Smith’s medical profile and the prescribed ‘metformin.’
• Human Errors or Factors: The nurse, due to fatigue, multitasking, or oversight, failed to read and administer the medication correctly. More rigorous training or periodic refresher courses could act as preventive measures.
• Communication Factors: The cardiologist verbally relayed the change in medication to the nurse. Reliance on verbal communication introduces potential gaps without written or electronic confirmation. Improved communication protocols, where critical information is both verbally discussed and electronically confirmed, can bridge such gaps.

Application of Evidence-Based Strategies

As exemplified in Mrs. Smith’s case, medication administration errors underline the urgency for evidence-based strategies in healthcare settings. Implementing these strategies to improve patient safety is crucial and grounded in rigorous research and studies. Many factors are pinpointed in literature as leading causes of medication errors.

The FDA has emphasized the challenges posed by phonetic and orthographic similarities between drug names, contributing to confusion (FDA, 2021). Furthermore, the pitfalls of verbal communication, especially in noisy healthcare environments, are highlighted by the ISMP (ISMP, 2019). Moreover, Jhala & Menon (2020)provided compelling evidence that interruptions during medication administration can escalate the risk of errors by 12.1%.

Evidence-Based Strategies and Their Application

• Drug Name Clarification in EHR Systems: Supported by the World Health Organization, technology that flags similarly named drugs can significantly diminish medication errors (World Health Organization, 2019). In Mrs. Smith’s scenario, a system that differentiates ‘metoprolol’ from ‘metformin’ would have prompted verification, preventing misadministration.
• Electronic Alerts in EHR Systems: The AHRQ (2019) advocates for enhancing EHRs to issue proactive alerts when there is a mismatch between diagnosed conditions and prescribed medications. Applying this to Mrs. Smith&