Root-cause analysis is used to point out the causes of adverse occurrences or explore options to prevent them from happening again. The root-cause analysis focused on medication errors and was performed in a nursing home facility following death of a resident patient due to wrongful discontinuation of the medication. This paper explores medication errors and looks at evidence-based and best practices methods to reduce medication errors. Further, the paper suggests a safety improvement plan with a basis on the use of available resources to address the problem.
The root-cause, in this case, was instigated by the untimely death of an 80-year-old at a nursing home. Angie broke her right; she was taken to the hospital and, after an ORIF was done, transferred back to the nursing home. Angie had been given new medications and ordered to continue taken her previous prescriptions as she had a known history of congestive failure that had lately presented with frequent exacerbations.
Having two medication administration forms in her file contributed to the error. The nurse administering the drug was also distracted by a phone call, signaled a colleague who unintentionally interpreted the indication of Lasix on the new MAR as duplication, and yellowed it out. The medication continued without administration of Lasix.
Consequently, presumed to have been discontinued, Lasix was removed from the cart and sent back to the pharmacy. Days later, Angie’s condition worsened, and resuscitation efforts proved futile. She went into a cardiac arrest and passed on. The sudden death of a patient who had recently responded to treatment affected the nurse in charge, who sought to probe the matter. The event also affected all the nurses at the home, the administration, and the physician who attended to Angie at the hospital.
The medication process has standard laid out procedures. In Angie’s case, the attending nurse should have pursued the yellowing of Lasix to ascertain the reason. The attending should not have removed the old Medication Administration Record from the patient’s file. Maintaining the said record in the patient’s file would have allowed drug reconfirmation when during the next round of administration. Given the history of Congestive Cardiac failure, the discontinuation of Lasix should have raised eyebrows, prompting further investigation into the reason behind such a decision.
Noteworthy is that the environmental factors that contributed to the sad occurrence were controllable. The distraction brought about by the phone call was too huge and the epicenter of the mistake. All stakeholders should have harmonized administration of medication. The communication was appropriate all through save for handing the file midway when picking the call. Therefore, the root causes for the grievous error were modifiable environmental distractions, failure to adhere to standard administration protocols, and modifiable environmental factors.
All nurses are vulnerable to committing medication errors. Workplace interruptions tend to increase the risk for medication errors, with Johnson et al. (2017) reporting that up to 99% of medication preparation or administration are interrupted. In this case, the interruption was the phone call, which caused the attending nurse to lose focus on patient needs and medications. A chaotic work environment can be detrimental to the results of nursing care. According to Johnson et al. (2017), the cost of medication errors remains high, and include lengthened hospital stay, lifetime physical injuries, increased cost of care, and in some cases, death of the patient.
For this reason, there is need for healthcare institutions to effectively leverage existing human resources to ensure full employer participation in improvement activities, staff training and promotion of smooth communication between the different stakeholders. Such initiatives can make it easier for facilities to handle challenges and barriers in patient care. Further, administrators should highlight the importance of complete and comprehensive patient documentation to minimize errors of omission.
The improvement plan for sustained patient within the facility will focus on three pertinent facets, namely improved communication between nurses and other stakeholders, enhanced collaboration, and elimination of detractors from the work environment, such as cell phones. The first step of this improvement plan entails improving communication between stakeholders to enhance a
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