Root cause analysis (RCA) systematically and methodologically investigates an occurrence to identify the reason for a system failure that might not be apparent initially after the incident. System and personal failures can lead to patient safety risks, including medication errors (Center for Drug Evaluation & Research, 2019).
A root cause analysis was conducted to investigate an incident in the surgical postoperative unit that involved a morphine overdose. The purpose of this paper is to describe this incident, conduct a root cause analysis, and develop a safety improvement plan to prevent these occurrences in the future in the organization.
Charlie is a 20-year-old white female who had an emergency appendectomy three days ago due to acute appendicitis. Today, he still complains of severe pain at the incision site and the abdomen. During the review in the afternoon, his surgeon prescribed oral morphine 10mg Stat for his pain and documented that prescription in writing in the patient’s physical records. The same evening, four other patients were admitted from the operating room and post-anesthesia care unit (PACU).
RN, the day shift nurse in charge of the room, delegated the administration of morphine to a student nurse because she was attending to the new admissions. Charlie had been on IV painkillers in the first two days but showed suboptimal pain control. The student nurse picked IV morphine rarely used in the unit, and administered 10ml instead of the 10mgs prescribed by the surgeon.
The surgeon, who happened to be the head of the department of surgery, and the nurse manager in charge of the department agreed that a root cause analysis of the issue be done because there had been prior near misses in the last in the same department.
The RN discovered the issue on her hourly reviews when she noted that Charlie was becoming drowsy and confused and had vomited twice about half an hour after drug administration. The event necessitated the use of naloxone use to reverse the side effects of morphine overdose. A multidisciplinary care team was formed that monitored Charlie’s postoperative healing and recovery.
The most common practice factors involved in medication errors include training, engagement, motivation, and work organization system. Interruptions commonly lead to medication errors by breaching the work organization system, thus increasing the risk of making medication errors of omission due to a break in concentrations (Schroers et al., 2022).
Possible outcomes are wrong medication, wrong dose, or wrong route in medication administration. Transitions in care provide a high risk of making medication errors. During this time, there are high chances of a break in the continuity of care, which can involve the patient medication lists.
Human factors contributing to the medication error included understaffing leading to nursing overload and delegation. The use of untrained personnel, the nurse student, to perform medication administration could contribute to the error due to inadequate competencies (Schroers et al., 2020).
Failure to double-check the prescription before medication administration led to the wrong medication and the wrong route of administration. A high patient-to-nurse ratio n could also contribute to medication errors from fatigue and burnout.
Documentation is a crucial method for interprofessional and intra-professional communication. Using manual documentation to provide prescriptions can cause medication errors due to illegible writing and confusion from lookalike sound-alike (LASA) drugs (Wondmieneh et al., 2020).
Communication is also important in medication reconciliation and double-checking the medication before administration. This could reduce the risk of medication errors in this case. Current methods of documentation utilize health technology to improve accuracy, efficiencies, and effectiveness in communication.
The nurse practice environment could also play a part in a medication error. Environmental factors such as shift and nurse staffing capacities can contribute to medication safety (Savva et al., 2022). Additional work is created for nurses in understaffed environments. This contributes to fatigue and exhaustion, which can cause medication errors.
The nurse, therefore, works to complete more tasks in a shorter time and may omit some tasks to save time. A surgical environment is a busy environment for a nurse, and completing all designated tasks can require additional speed. In Charlie’s case, poor documentation, understaffing, lack of communication, and poor care transition were the root causes of
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