NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ
Introduction
Root cause analysis is described as a range of possible approaches and tools obtained from the human factors and safety (Andersen and Fagerhaug, 2006). It provides the methods of identification of structured risks and their management in the aftermath of certain adverse events (Latino et al., 2019). This analysis is used to establish the ‘how’ and ‘why’ of the procedure and event with an attempt to identify the similar events. The application of root cause analysis is crucial in the health care system in improving the learning and incidence of mishandling (Peerally, et al., 2017). A root cause analysis of the medication administration errors in hospitalized patients was conducted. This paper describes the causes of the medication administration errors, regarding dose amount and negligence of changing notes, evidence-based solution strategy and planning to prevent such errors and ensure patient safety and quality of health in the organizational setting using the.
Scenario for identifying root cause analysis
35 years old, Major, male, was admitted to the hospital in the general ward. He had a high BMI of 31.5, obese with complications of psychological eating disorder and stress. He had severe implications of diabetes and was prescribed with insulin doses two times a day before a meal, in the morning and at night, The nurse had to administer the dose of insulin intravenously after evaluating the glucose and keep a monitoring record on the retroactive chart. The night shift nurse measured the glucose to be normal, so she did not record it on the patient’s sheet. However, the nurse was required to report the readings to keep a record. The night shift nurse did not even verbally communicate with the morning shift nurse about the patient’s needs. Later the morning shift nurse couldn’t find the record of the previous administration of insulin, current glucose was 400 and she could find the clinical physician because of the busy floor. The strict timely administration policy of the medication took the nurse under pressure and she administered the two doses of insulin. Later the patient went to hypoglycemia with a feeling of dizziness and vomiting. The nurse felt guilty and was responsible for the error and the patient’s health. The medical error occurred due to multiple reasons, lack of communication, poor record-keeping and documentation on the retroactive sheet, increased workload pressure of work efficiency. The lack of communication and coordination of the nurses lead to suffering the patient from the previous condition of health degradation.
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ
Root cause analysis of the medication errors
The root cause of the medication error observed was multicentered related to the organizational, environmental and individual factors. The increased load of the work and busy floor reduces the quality of work, The lack of coordination of the nurses caused the patient to suffer. The nurse of the previous shift was supposed to administer the insulin and report it on the sheet, rather the nurse did not administer the insulin and did not even report it on the sheet which led to miscommunication of the documentation. Medication administration is a key responsibility of the nurses; however, several nurses have reported certain environmental and individual factors (Friedman, et al., 2007) can interfere with the efficient medicine administration including, fatigue, workload, carelessness, negligence on nurses ends, poor coordination and communication between the nurses, inadequate balance of the staff and patient load, overcrowding of the hospitals and poor understanding of the procedure of administration (Shahrokhi, et al., 2013).
Considering the frequency of medication errors, poor coordination and documentation are the grassroots of multiple errors in health care. Efficient record-keeping of the medication, enough workforce and a positive working environment can influence the medication errors (Teixeira and Cassiani, 2014)
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan JJ
Evidence-based strategies
The safety of the patient is the core of health care provisions. Simulating a culture and organizational change of reporting the harms and preventing the adverse effect of the disease can enhance the efficiency of quality care to patients
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