A root-cause analysis is a method of problem-solving that entails determining the primary reason for a situation or issue to stop it from happening again in the future. Investigating the root causes of safety problems and potential remedies is often part of a safety improvement plan.
Organizations wishing to increase safety and prevent accidents or incidents must apply root-cause analysis and safety improvement planning. Organizations may make their workplaces safer and more productive for both their employees and clients by recognizing and addressing the fundamental causes of issues. This paper aims to conduct a root cause analysis of an incident that risked patient safety in my health organization and develop a safety improvement plan from the analysis.
Mr. X, a 52-year-old black male, had been hospitalized for three days for treatment but was diagnosed with stage II hypertension during his inpatient stay. As part of his treatment plan, he was prescribed Lisinopril tablets, a medication used to lower blood pressure, to be taken once daily at a dosage of 10mg upon his discharge from the hospital. The medication was dispensed by a licensed pharmacist, who checked that it was the correct medication and had not expired. However, the pharmacist made a mistake and provided the patient with 20mg tablets of Lisinopril instead of the prescribed 10mg tablets.
The patient, who was also a healthcare professional, took the medication as directed and subsequently experienced severely low blood pressure and dizziness, requiring emergency care the next morning. This error occurred despite the pharmacist’s efforts to ensure the accuracy and safety of the medication. The patient received treatment at the emergency department and recovered from the adverse reaction to the medication. This incident highlights the importance of careful medication management in preventing adverse events and the need for proper training and oversight of healthcare professionals.
The nurses discovered this problem at the emergency department who, during medication reconciliation and health history building, questioned the patient’s past medical and medication history. The nurse wanted to know the reason for this unplanned readmission within 48 hours after discharge. The patient, Mr. X, was impacted by the issue or event in the scenario mentioned above. Mr. X’s extremely low blood pressure and disorientation were caused by the pharmacist’s mistake in the medication he dispensed, necessitating emergency care. As a result, Mr. X had a great deal of stress and inconvenience, and it is possible that this had a detrimental effect on his physical and mental well-being.
The error might have potentially resulted in long-term effects if it had not been caught right afterward. Patients who experience medication errors may experience adverse side effects, damage, or even death (Assiri et al., 2018). Healthcare providers must adhere to established protocols and procedures to ensure patient safety and minimize avoidable mistakes. Healthcare providers must adhere to established protocols and procedures to guarantee patient safety and minimize avoidable mistakes. Patients should be knowledgeable about their prescriptions and speak out if they have any concerns or inquiries.
As part of his hypertension treatment plan, Mr. X was given a prescription for Lisinopril pills at a dosage of 10mg once daily and was meant to be discharged from the hospital. A qualified pharmacist was required to dispense the drug and ensure that it was the right one and that it had not expired. However, the pharmacist misread the prescription and gave Mr. X 20mg of Lisinopril tablets rather than the 10mg tablets that were intended.
Despite the pharmacist’s best efforts to ensure the medication’s accuracy and safety, this error nonetheless happened. The usual chain of medication use in the facility is that upon the prescription of medication by the physician or an advanced practice registered nurse, the nurse should check the prescription and obtain the correct medication from the pharmacists.
In case of uncertainty, the nurse, as the professional administering the medication, should check with the prescriber to ascertain that the prescription is safe and appropriate for the patient and that all the five R’s of medication use are considered in the prescription. The pharmacists should ensure that the patient gets the right medication with the correct dose per the prescription. In cases of uncertainty, the pharmacist should check with the prescriber and professional administering the medication to prevent errors. Another role of the nurse in this system is ensuring that the pat
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