Root Cause Analysis (RCA) is being used widely for understanding factors that are the main reason for medication errors. Instead of keeping the blame on an individual, an identification system of specific factors might contribute to reducing the rate of medication errors. RCA has been performed on a medication incident where competencies of nurses have been evaluated finding the factors that were involved in a medication error. Factors that are majorly involved in medication error include environmental influence, personal (irresponsibility of nurses), unit communication, cultural impact, or lack of education. RCA provides a fair culture for the nursing education system where nursing students and staff identify problems and work on them to find an appropriate solution.
Medication errors are life-threatening for patients and are known to be on 8th number of death causes in the USA. It not only threatens human life but also is crucial to the cost effects of medicines. The root cause of medication errors is to be evaluated from the medicine prescribing process until the administration of medicine. According to root cause analysis results, medication errors are either in the form of incorrect dose, wrong drug registration, incorrect entry list, or wrong medicine formula. 20% of medication errors are due to incorrect order check of medicines, 15.5% are readability errors,14% errors are in terms of a similar name, form, or appearance of medicine, 7.8% are due to the short-hand name of medicine written by doctors while 8.7% are due to incomplete names of medicine written by nurses. Considering patient safety as an important factor and safe hospital services, identification of errors is very important along with finding the causes of error production. RCA helps best in this concern to find the cause and apply strategies to overcome the medication errors (Rezaei., 2019).
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RCA helps nurses in the identification of systematic or other reasons for occurrence along with immediate error causes. Along with identifying the direct source of error/problem, identification of the root cause is also necessary. Finding the direct error source can be helpful for a short period but it will not completely cure the issue while finding of root cause will be beneficial enough that not the same type of error can occur again. Responsible health professionals or nurses for the medication error should provide a pre-determined answer for each cause. From the outcome of the RCA analysis, it is suggested to implement error prevention strategies that should focus on policies and procedures along with strong communication among physicians, healthcare professionals, and nurses. Understanding the root cause has clinical significance to find preventive measures for medication errors.
Risk management is a complex combination of clinical and administrative procedures that detect, assess, and prevent patients from risk. The healthcare organizations have a systematic way of evaluation through RCA which helps optimize the patient care and implementation of plans to reduce medication errors. RCA keeps the individuals focused on systematic procedures by which individuals’ activities can be analyzed. RCA enhances the performance of patient safety and improved healthcare facilities. Combined RCA analysis of sentinel events can play a key role in improving an organization’s healthcare facilities and patient safety procedures by providing the risk factors and root causes of problems. RCA has been performed in a regional teaching hospital in the Netherlands, by combining the key characteristics and variables of sentinel events to find the pattern of causative factors that are involved in error production or failure of any plan/event.
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