A root-cause analysis is a systematic method for determining the underlying causes of an adverse event (Spath, 2018). The fundamental causes of issues in nonclinical work can be found using the RCA, a structured research procedure (Spath, 2018). RCA starts as soon as a sentinel event, harmful occurrence, or near miss occurs (Spath, 2018). As is the case with all improvement projects, a team is put together to carry out the investigation (Spath, 2018). Some experts advise the RCA team to speak with those who were present for the event but not to include them in the team (Spath, 2018). This is done to lessen prejudice and enable open discussion of potentially sensitive topics in team meetings (Spath, 2018). The team leader should ideally know the RCA investigative method (Spath, 2018).
For this week’s discussion, a root-cause analysis team (RCA) was put together to investigate the medication errors that occurred at Downtown Medical. The risk manager, who serves as team leader and mediator in this scenario, a full-time staff nurse, and a full-time pharmacy technician make up the RCA team. The staff nurse from the unit where the incident occurred brings expert knowledge on the medication administration process and any barriers nurses face. The pharmacy technician has extensive knowledge of his department’s workflow, the procedure for filling and dispensing prescription carts for nurses, obstacles in the pharmacy department, and flow chart experience. The risk manager will contribute to coordinating the team and assist in obtaining data to analyze root causes and find a workable solution.
In the given scenario, the risk manager did a great job acting as a mediator between the staff nurse and pharmacy technician. The RCA team investigated the root cause of the medication errors. They developed a flow chart, a cause-and-effect diagram, and a Pareto chart showing the medication errors that happened last year. The most frequent defect or defect source is highlighted using a Pareto chart. The Pareto test diagram demonstrated that the bulk of errors happened during the stages of the medication administration process (Rabou et al., 2017). Fishbone analysis or Root Cause and Process Flow Analysis were utilized during the measure phase to identify the numerous difficulties and interruptions when administering medications (Rabou et al., 2017).
The three leading causes of pharmaceutical errors, as indicated by the data presented in the Pareto Chart, are look-alike medicine labels (22%), pharmacy tech stress/error (22%), and malfunctioning scanners (37.5%). The team can concentrate on identifying and creating solutions to reduce medication errors by using the data from this graphic. First, ensure reliability, and ensure scanners are frequently changed and maintained. When no scanners are available, a downtime process policy should be in place. The pharmacy could also possibly have a second employee perform a quality check to confirm that identically labeled medications are not kept together in the same drawers or compartments. Third, the pharmacy must analyze the factors contributing to pharmacy technician stress and mistakes. It might be necessary to solve their personnel and workload problems. The RCA team will conduct further brainstorming, develop new ideas, and implement actions to reduce drug mishaps.
Complex systems that are poorly built contribute to healthcare errors (Rabou et al., 2017). Assessing the severity of the error should go hand in hand with identifying the reasons for pharmaceutical errors (Rabou et al., 2017). Programs for reducing the frequency of all drug errors should be included in quality management systems, and efforts should be focused on eradicating the root causes of more severe errors (Rabou et al., 2017).
References:
Rabou, F. M., Saad, H. A., & Ella, S. M. (2017). Interdisciplinary collaboration for investigating medication errors causes: Six sigma methodologies. IOSR Journal of Nursing and Health Science, 06(03), 50–58. https://doi.org/10.9790/1959-0603065058
Spath, P. (2018). Introduction to Healthcare Quality Management. Gateway to Healthcare Management.
ROOT CAUSE ANALYSIS
Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
BY DAY 3
Post each of the following:
Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.
Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.
Explain the team’s process in testing for and eliminating root causes that were not contributing.
Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.
Identify the contributing factors and discuss how to prevent this kind of error from occurring in the future.
Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level.
Notes Initial Post: This should be a 3-paragraph (at least 350 words) response. Be sure to use evidenceLinks to an external site. from the readings and include in-text citationsLinks to an external site.. Utilize essay-levelLinks to an external site. writing practice and skills, including the use of transitional materialLinks to an external site. and organizational framesLinks to an external site.. Avoid quotes; paraphraseLinks to an external site. to incorporate evidence into your own writing. A reference listLinks to an external site. is required. Use the most current evidenceLinks to an external site. (usually ≤ 5 years old).
BY DAY 7
Read and respond to the postings of two or more of your colleagues’ who discussed different charts, identified different evidence of positive collaboration, and/or identified different contributing factors than you did. Also offer comments that ask for clarification, provide support, or contribute additional information. Offer alternative viewpoints on the cause as you see it.
Post a Discussion entry on three different days of the week.
