Root Cause Analysis of the Wrong Medication NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

The root cause analysis of the situation that is being discussed is based on multiple perspectives, with the aim of finding every possible loophole that might have led to the medication error in a heart patient.

1. Prescription stage: The most significant error that might have occurred on the whole was associated with a wrong prescription, incomplete patient information, or the pharmacist’s inability to read the doctor’s prescription accurately. If the patient’s information is incomplete or missing, chances are that the prescription may be wrong as their entire history is not clearly seen.
2. Misinterpretation of Physician Writing: Many errors occur due to the inability to read the writing of the physician or typing the wrong spellings of the formula, which may change the entire class of medication that has been prescribed.
3. Misreading of the prescription: At times, the issue is associated with the pharmacist not being able to carefully pack the medication, thus leading to the medication error.
4. Administration stage: The fact that the nurses or the administration staff handed over the wrong medication may become a potential cause of concern for the patient.
5. Monitoring and follow-up stages: Lastly, the fact that the nurses or the healthcare providers failed to assess the efficacy of the medication in the monitoring or in the follow-up and continued a medication that was not beneficial for the patient

Quality Improvement Actions

The quality improvement actions allow the physicians as well as the nurses to become prepared for such issues and have a better plan to combat them in case of emergencies. Thus, to increase patient safety, the following plan can be implemented:

• Enhance Medication Safety: Patient safety is of paramount importance, so the first step in improving medication management is to streamline the medication administration process. This can be done, for example, by using a patient entry order that sorts medications alphabetically by their formula names rather than their brand names. Other methods could be using the barcodes or identifying specific medical dispensaries where people can buy those medications.
• Communication in Teams: Having a standardized handoff protocol would also help in establishing clear and guided communication and information exchange, which increases patient safety and the quality of care that is being provided. Similarly, promoting effective teamwork and communication among other healthcare providers, such as nurses, doctors, and pharmacists, can increase the safety of medication.
• Patient Engagement and Education: Another way to promote medication safety and improved healthcare is by engaging patients and educating them so that they become capable of taking care of their medication and reduce the risk of error on their part. This also encourages them to take initiative and express their concern regarding medication. Having programs regarding health literacy can help in understanding the educational materials and instructions and reduce medical errors.
• Use of technology: Electronic health records, computerized patient entry, or automated alarms can help in remembering the record and type of medication that is being utilized, allowing patients to become aware of the medication while the government has authorized access to the patient’s medical history and medication they are currently taking.

Quality Improvement Initiative.

The aim of the quality improvement initiative with respect to rescuing future adversities was designed to reduce medication errors in hospitals through the implementation of evidence-based practices and strategies.

• The first strategy is to establish an all-rounded team. Such as having a team that consists of representatives of nursing, physicians, pharmacists, quality improvement staff, and IT members to ensure that the medication dispensing is accurate and without any error.
• Second, conducting a baseline assessment For every issue, the most important thing is to develop a baseline assessment through reviewing reports and events associated with identifying the probability and reasons for a near miss.
• Then, having set goals and clear expectations makes it more approachable for the patient as well as the healthcare providers.
• Then, having strict policies regarding incidence and a clear action plan can help every individual involved be sure of the consequences of their mistake and ensure a quality hospital.
• Similarly, having computerized prescriptions and standardized medicatio