NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Root-Cause Analysis and Safety Improvement Plan
In this assessment, we will apply the root-cause analysis and safety improvement plan, where the main issue and its reasons will be discussed in depth. Defining root-cause help in building the structure for improvement of patient safety and medication administration in an organization. Furthermore, the appropriate strategies will also apply to address the issues or sentinel events about medication administration. The assessment will help us find the defined issue’s improvement and safety plan while penetrating the existing organizational resources (Bates & Singh, 2018).
Analysis of the Root Cause
Medication errors or medication administration errors are most common type of errors that occur in a hospital. In the United States, each year, many hospitals face the allegation of prescribing or injecting the wrong medication to the wrong patients. Similarly, the incident occurred in the St. Luke Magic valley. They faced a huge disruption due to their medication error in which the nurses mistook the adult’s patient medication for the infant’s medication and infused the infant with cardiac medication. This medication administration error caused the child’s death after 10 minutes of injecting the medicine. Losing one life can be a real threat to the hospitals and an unbearable loss for the families (Prentice, 2020).
Hence, it is essential to figure out what went wrong and what made the situation worse. Proper investigation is required to find out the incident’s root cause and help organizations prevent such incidents in the future. This medical malpractice was performed by the St. Luke’s Magic Valley Regional Medical center, and the reason was a lack of consideration and losing focus to double-check the medication. In the investigation, the nurses explained that the medication bags were similar with different labels, which made the nurse believe that the medicine was for an infant without double-checking the label. This incident happened at night at almost 11 pm, and most of the staff were off-duty due to staff shortage, the nurses in the nurse station were occupied with labeling medicines for the medication (Gates et al., 2019). During the process, one nurse took a medicine bag from the nurse station that was prepared for the adult patient, especially for a cardiac while on the other side; the infant also had heart disease, so due to similar bags, the nurses administrated the adult’s medicine to the child. This malpractice caused a huge loss for the family due to the hospital’s liabilities. They agreed that the nurses played their duties poorly and lacked ethical codes and communication, which led to the unbearable loss (Koyama et al., 2019).
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Application of Evidence-Based Strategies
After the incident, the hospital management and authorities took serious action and admitted their mistakes of being so unprofessional and unethical. They stated that they missed the standard procedure for administering medication, and they are deeply regretting the loss. The authorities also claim that they imposed better strategies and guidelines after the accident and tightened their process to mitigate the chances of human error in the near future.
Some best practices were considered to address the safety issues or sentinel events regarding medication administration, such as the implication of barcode systems and medication preparation for one patient at a time. Because of workload and understaffing, the nurses were so busy preparing different medication bags in the nurse station that to forget to double-check the medication administration. Planning for medication administration to avoid malpractices is necessary; otherwise, the hospitals would encounter safety issues (Tariq & Scherbak, 2021).
The implication of the Barcode Medication Administration System (BCMA) will also help nurses to provide the right prescribed medicine t the right patient despite their busy schedules (Zheng et al., 2020). The Barcode system will analyze the detailing of the medication, such as expiry date, patient information, medication information, and most importantly, the selection of the right medication bag. Smart infusions, single-use medication packages, and pumps for intravenous administration (IV) are some strategies to enhance patient safety issues related to medication administra
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