Root-Cause Analysis and Safety Improvement Plan
It was just a few months ago that a medication error happened within our healthcare organization. A new medical officer joined the organization and a few moments after another client had no longer required the medicine, he placed sulfonylureas in the cage containing enoxaparin. The problem was resolved before it had the opportunity to have disastrous effects. The paper seeks to examine this scenario and analyze it. A strategy for implementing evidence-based practice, as well as improvement approaches and organizational resources, will be included as well.
Analysis of the Root Cause
In this situation, the patient needed enoxaparin to be administered. The nurse who was responsible for administering the medications headed to the pharmacy and removed the medication from its container, just as he usually did. Practitioners are required to input medicines into the system in accordance with patient care and data, as stipulated by the facility’s regulations. After scanning the medicine, he received an error message stating that the medication was incorrect on two occasions. Because he had hurried and the device was prone to function poorly, he occasionally utilized the alternative of override to keep inputting the other medicines. He administered the medicine in accordance with the prescribed dose of 1.5 ml; nevertheless, after a short period, the nurse saw that the patient was looking agitated, disoriented, and wobbly. Because of the sudden onset of clinical symptoms of hypotension, the nurse felt that the medicine had to be the cause of this occurrence. He proceeded to the pharmacist’s station and handed her one amp of D50, which is considered to be effective in the treatment of hypoglycemia in the event of an unexpected low blood glucose level. The problem was investigated further and it was discovered by the nurse that medicine had been placed there by mistake.
It is possible that negligence and failing to adhere to the facility’s procedures, among other things, resulted in the current situation. When used correctly, the system’s significance is that it is intended to minimize similar medication errors from occurring. Despite the fact that the system is notorious for misbehaving, the nurse should have investigated whether the mistake was legitimate or the result of a system malfunction. Furthermore, the pharmacist disregarded the medication storage standards that were in place at the facility. The inability of the pharmacist to arrange the medicines according to their kind was the root of the problem.
Moreover, the nurse failed to adhere to the five rights of medicine delivery as recommended. The five rights are intended to guarantee that the appropriate medicine is administered to the appropriate patient at the appropriate dose, at the appropriate time, and through the appropriate channel (Martyn et al., 2019). The nurse may be alerted to the inaccuracy and prevent the medication from being administered if this procedure is followed.
It appears that inadequate communication with the pharmacist has an impact on routine, which is critical in the promotion of coordinated care. Studies have found that good communication is critical in encouraging cooperation among clinicians and improving coordinated care. The pharmacist was inexperienced, and her error might be ascribed to the individual who helped her become acquainted with the job. Aside from that, environmental variables such as a client not requiring medicine, medications being of comparable appearance and size, and nurse practitioners being preoccupied all contributed to the problem.
Human errors that contributed to the incident include the pharmacist placing the medicine in the incorrect location and the nurse failing to verify the medicine before administering it to the patient. Despite the fact that drugs may be kept in identical containers and seem the same, the health data system and laboratory instruments should detect the mistake before it happens. In addition, the equipment is old and ineffective. Because it occasionally displays errors when none were present, the nurse assumed it was the same situation and did not raise the issue with the doctor. On closer examination, it becomes clear that the root cause is a combination of faulty equipment, inadequate knowledge, ineffective communication, and failure to follow a specified model of care.
Application of Evidence-Based Strategies
A large proportion of medication errors are attributed to communication breakdowns and human error. Medicines may be misidentified by a nurse or other healthcare worker, particularly if their appearances are similar. As pointed out by Breuker et al. (2017), good communication skills between healthcare providers may minimize over 80 percent of medication blunders. Because of the absence of effective communication methods, as