Healthcare institutions use Root Cause Analysis (RCA) by safety improvement teams to post adverse events, assisting in the determination of a deficiency in its own system. The medication error at
Downtown Medical led to a RCA investigation to determine what deficiency resides within its own system. It was a systematic approach to decipher the cause of the medication adverse event, with the attempt of developing a plan for the prevention measures of a repeat (Spath, 2018). Team members of the risk manager, a full time nurse, and a pharmacy technician all professionally capable of critically contributing in positive terms through experience, expertise, years of training, and a broad knowledge base.
Collaboration in this case study that led to effective problem solving began with the professional approach to putting aside squabbling and finger pointing with the aim of RCA pertinent to the prevention of such event recurring. Evidence in the scenario demonstrating effective collaboration was the apologies shared and ownership of department involvement towards reconciliation for a solution.
The team’s process in testing and eliminating root causes came in the form of a Process Flow Chart, the Pareto Chart, and the Cause-Effect diagram. Collecting the data, displaying the data, comparing the results against clinical expectations helped to determine a need for corrective actions. The Pareto Chart most clearly outlined the root causes not contributing towards the medication error event per the last five empty bars in its chart.
The Pareto Chart was vivid in outlining root causes in data distribution in 2015. It emphasized and separated three major problems from the rest of the data displayed in the chart. This special type of bar graph clearly highlighted the most problematic root causes within the first seven bars. Contributing factors of defective scanners, look-alike medication labels, and pharmacy tech stress and errors must be analyzed and corrected through the application process of improvement models. Utilizing improvement models for such a practice problem will lead to measured improvement. Yoder-Wise (2019), concluded that planned change by healthcare organizations must be deliberate, yet organized when planning goals toward improvement.
“When patient safety is compromised, it is critical to get to the root of the issue in order to determine how to ensure patient safety and avoid risks in the future”. Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care. According to WHO, patient safety is “the prevention of errors and adverse effects to patients”. The principles of patient safety can be categorized as risk management, infection control, medicines management, safe environment and equipment, patient education and participation in their own care , prevention of pressure ulcers, nutrition improvement, leadership, teamwork, knowledge development through research. To ensure successful implementation of patient safety strategies, there must be in place: clear policies, leadership, data to bring about safety improvement,skilled health care professionals and effective involvement of the patients in their own care. Medication errors are a leading cause of injury and avoidable harm in health care systems; globally, the associated cost has been estimated to 42 billion dollars, annually.With the use of Computerized Physician Order Entry (CPOE), On line nursing documentation in the EMR and Bar coded Medication administration, you will think that medication errors should decline, but despite, we still continue to have medication errors.Hence the need for Root Cause Analysis (RCA).
A Root cause Analysis (RCA) is used to determine the cause of an incident and improve safety by identifying system flaws (Spath, 2018). The RCA team consisted of a staff nurse, a pharmacy technician and a risk manager (Laureate Education, 2016a,2016b). The team were able to contribute to the RCA: The nurse who works full time could provide information on the difficulties on the floor when it comes to scanning medications such as a non-functioning scanner, or a damaged label. The pharmacy technician could offer details on how to make the scanner work or to contact the pharmacy for a scan able tag. The risk manager could provide information on how to get to the bottom of the root cause by being the mediator and showing strengths and knowledge of the process into the situation. Together, the team can find a successful long term change to prevent error by adopting new practices (Yoder-Wise,2019). Having a team leader can help to resolve conflicts (Yoder-Wise,2015). In the video, the nurse and the pharmacy tech both started off, on the defense that the other department was responsible for the error.The risk manager was able to step in and take control of the meeting before things became uncontrollable and was able to keep the members on track for the duration of the meeting. If the risk manager was not there or not knowledgeable enough to keep them under control, the meeting would have been unproductive. At the time when the team members began the discussion that were not related to the case at hand, the risk manager agreed that it needed to be discussed, but at another time . The nurse was able to own up to her mistake of pointing fingers at the pharmacy, apologized. The team was able to stay focused on the issue at hand, had time to discover ways to prevent further occurrence (medication errors) in future. The use of a bar code scanner could have prevented the error from occurring i.e., the nurse could have scanned the medication,and the pharmacist should have assisted the nurse with why the the medication could not be scanned instead of telling her to go ahead and give the medication.In the first meeting, the staff nurse and the pharmacy technician had knowledge of their individual department work flow methods and were able to bring their concerns to the table, developed the work flow process chart etc, developed a cause and effect diagram plus a year’s worth of medication errors that were plotted on a Pareto chart.
According to the data plotted on the Pareto chart, the three major contributing factors for the medication errors are (1). the defective scanner with a 37.5%, Look alike/Sound alike medications of 22% and pharmacy technician stress/error of 22%. By utilizing the information from this chart, the team can focus on finding and developing solutions to prevent further medication errors by: (1) Ensuring that the scanners are functioning well or replaced , and regular maintenance checks of the scanners for reliability, (2). Putting in place, the Downtime procedures protocols in cases of faulty scanners, (3). Pharmacy, making sure that the Look alike/Sound alike medications are packaged distinctly and labeled (maybe in different compartments) and have a second nurse check/witness such medications before their administration to prevent errors, (4). Evaluating the cause (s) of pharmacy technician’s stress/error and fix the problems e.g. Heavy/Overwhelming workload, staff shortages resulting in long shifts which can cause burnouts. The RCA team should always brainstorm, identify problems and develop solutions or implement initiatives to prevent medication errors.