There needs to be an emphasis on mitigating the factors that cause adverse events like medication errors. The specific safety concern that has been recognized was with the young patient Sam who was diagnosed with cancer. Upon difficulty eating he was given an infusion pump, it was brought to the nurse’s knowledge 5 hours later that the infusion rate was incorrect. More such cases occur in the healthcare facility, some also go unreported.
Root cause analysis is highly helpful as it allows medication errors to be identified. Since medication errors are common and avoidable, root cause analysis allows for addressing important patient care aspects (Singh et al.,2022). It allows important steps to be taken to improve communication and different facilities to prevent medication errors. This paper will help analyze the root causes of patient safety issues, apply evidence-based strategies to that issue, and create a safety improvement plan.
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Analyzed the Root Cause of Patient Safety Issue
The patient safety issue as discussed before is the infusion pump in this paper. 1,004 events of medication error were recorded in 2018 across Pennsylvania that involved the use of an infusion pump. Some of these cases were of high alert and concern (Taylor & Jones, 2019). User programming was identified to be the major cause of this issue. Either the IV is not connected properly, the device malfunctions, the device is not maintained properly, or the patient intentionally or unintentionally programmed the pump themselves.
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Among several medication errors, infusion pump errors have been identified to be one of the most prevalent. The carelessness or lack of communication can cause incorrect programming that may lead to such errors. The patient may even avoid programming themselves if there was proper communication not only amongst the nurses but with the patient too about their treatment. Infusion pumps can cause inefficiencies leading to errors largely due to time taking indirect patient care tasks that are associated with infusion pump procedures like searching for pumps, manual programming, responding to false pump alarms, managing tangled tubes, and priming tubing (Bacon et al., 2020). Such inadequate workflows lead to inefficient communication, delays, and care gaps. It is also important to highlight that lack of training and knowledge can lead to a lot of rule-based mistakes with infusion pumps.
Applying Evidence-Based Strategies to Address this Safety Issue
The harm that such errors with infusion pumps cause is considered to be a major failure of the health care facility and should be mitigated to gain patient trust and ensure their safety. A series of tests were done by a multidisciplinary team on infusion pumps and different approaches were identified (Porte et al., 2020). The 2-person verification approach was considered to be the best to reduce error and prevent time delays.
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