Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis
This paper will discuss the root-cause analysis (RCA) related to a medication error that occurred in a Skilled Nursing Facility. Here, a nurse gave a medication via the wrong route. An analysis of the root cause of this medication error is a critical step in decreasing medication errors. First, evidence-based, best-practice strategies will address the medication error. Next, a viable, evidence-based safety improvement plan for safe medication administration will be proposed. Last, existing organizational resources that could improve the safety improvement plan will be identified. Nurses need to understand and take part fully in the RCA process. Through RCA, the how and why of the medication error can be reviewed while using a collective method in investigating the incident and pinpointing areas that must change (Haxby & Shuldham, 2018). RCA is a method that looks back on the error to find the cause of the error and then change the behavior so that it never happens again. The goal is to provide safe care to the patient. Analysis of the Root Cause The nurse accidentally administered Debrox (an earwax medication) into the patient’s eye. The patient immediately felt that the wrong medication was placed in her eye as her eye burned, which frightened her. While this did not cause sentinel harm to the patient, the patient only had one functional eye, and she could have lost the vision in that eye. In addition, the patient and her family could have lost faith and trust in the nurse because of this error. This unfortunate error also affected the nurse, who felt terrible as she had caused harm to a patient. In addition, she felt embarrassed in front of her peers that she had made such a mistake. Yes, the nurse could list many excuses which contributed to the medication error. She was distracted in the medication administration. She had 30 patients for which she was responsible.
3 There should have been two CNA’s assisting the nurse, but only one worked that shift. Distractions from multiple patient needs were rampant. Several call lights were going off with no one to answer. The nurse was tired as she was working a double shift as another nurse had called off. The nurse was in a hurry, distracted by multiple responsibilities. Perhaps she was hungry or thirsty as she could not take a break for several hours. She could have been feeling angry at the staff members who had not come to relieve her. However, the fact is that she had not followed the proper policies and procedures for medication administration. Not following the correct procedures was the principal cause of the medication error. The proper procedure would have been to review the five rights of medication administration (right patient,
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