Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan
Root cause analysis is the process of trying to figure out where the problem came from and what caused it. Before that, you need to figure out what the problem is, then look for its causes and possible answers. The answers are supposed to make the results better, but if they don’t, root-cause analysis is done again to find out what else could be done to make things better. This essay will talk about medication errors, figure out why they happen, and come up with a plan for improvement that will help the company make fewer mistakes.

A look at what’s really going on

Medication mistakes happen to a lot of people in the United States, and some of them may die because of it. The National Center for Biotechnology Information says that about 8,000 Americans die every year because of mistakes with their medicines. (World Health Organization, 2016). Also, thousands of other people have problems because of mistakes with their medicines. Also, fixing these mistakes is expensive for both the building and the person who made the mistake. Medication mistakes can cause physical and mental pain, and they can also have financial and physical effects that are hard to deal with.

Medication mistakes make people lose trust and be unhappy with the health care they get. When health care workers make a medical mistake, like giving the wrong drug at the wrong time, patients think that they are not skilled or trained. But since this might not be true, it is hard to persuade the patients of this. After something like this happens, they look for other places or service providers because they don’t trust the first ones. Medication mistakes and other kinds of medical mistakes can cost a business a lot. Still, medication mistakes can be avoided by taking a number of steps to make sure people are competent.

Schroers, Ross, and Moriarty (2020) say that there are a number of reasons why medication mistakes happen. At the Lafayette Villa nursing home, the nurse in charge did a root-cause analysis to find out why there were so many medication mistakes. Some of the reasons that have been found are that doctors don’t talk well with each other or with nurses. When healthcare workers can’t talk to each other, patients suffer because they don’t get the care they need and a number of possible medical mistakes can happen. The other thing that was brought up was that some of the medical terms were almost the same. During drug giving, the nurse could mistakenly give one drug for another. The patient would then have to deal with the effects of these mistakes. In the same way, the way drug names are pronounced can be similar, so it was found that nurses sometimes switch around some drugs, which can lead to a medication mistake.

Last, working too much can lead to burnout. Medical staff burnout stood out from the rest and was found to be the main cause of medication mistakes. It was the main cause of the most drug mistakes. Due to not having enough nurses, the ones who were there got tired, which kept them from doing their jobs well. Medication mistakes happen when the five patient rights—right patient, right time, right amount, right drug, and right route—are not followed. (Gilani, 2020). When nurses were too busy, they sometimes gave medicines to the wrong patients or used the wrong way to give them.

In addition to nurses being tired, other things that take their attention away also lead to drug mistakes. Studies have shown that nurses are more likely to be distracted on the job than the rest of their team. (Johnson et al. 2017). So, it makes them more likely to make mistakes in mediation than people in other fields. Family members, warning bells from the patients, new patients, emergencies, and phone calls from other departments can all be sources of distraction. Even though they are part of a nurse’s job, they can get in the way when giving medicines. Part of the problem with interruptions and distractions can be fixed by hiring enough people who can be put in charge of specific tasks.

Plan for improvement with strategies based on facts and best practices

Based on what was found to be causing medication errors at Lafayette Villa Nursing Home, the improvement plan includes helping the doctors, doctors and nurses, and health care workers who work with patients to talk to each other and the patients better. Communication is important for making a diagnosis, writing a prescription, and even giving a drug. By teaching health care workers how to talk to each other well, drug mistakes and other missed information will no longer happen. All healthcare workers are also told to only use standard medical abbreviations that are accepted by both the medical board and the organization. This is to avoid confusion that can lead to medication errors. Also, nurses are told to be more careful and attentive when handling drugs with names that are almost the same so that they don’t get mixed up.

In the case of burnout, the organization was expected to move quickly to make sure there was enough staff or that the tasks could be handled. Having enough staff can help prevent stress and reduce medication mistakes. Still, it is important that the nurses check the patient’s five rights with a second set of eyes before giving them a drug. The second set of eyes makes sure that drugs are given correctly, which cuts down on mistakes. The other most important plan is for nurses to learn how to get the patient involved. They should know what medicines they are taking, how much, how often, and for how long. If a different drug was given by accident, they would be careful to tell the caregiver, which would cut down on the number of possible medicine mistakes.

Other measures to help include giving people in the business more power to work as a team. At Lafayette Villa Nursing Home, staff should be praised for good work. People who do great work should be honored and given awards. Staff are more likely to work hard and do a good job because of this, and medicine mistakes are less likely to happen because everyone wants to be the best. A boss who is vocal and helpful can also be chosen. Each member of the staff will look to the leader for advice and help with their own problems. If the staff knows they are being watched closely, they will be careful in everything they do to keep their good name. Leaders can help nurses do their jobs well, get things done on time, and reduce the chances of mistakes.

Lastly, the company can try to improve or change the environment as part of the improvement plan. The environment is to blame for the delays and distractions, and the environment can be changed to make things better. Family members can cause distractions, such as alarm bells from the patients, new admissions, emergencies, or calls from other departments. Because of this, there can be a controlled flow of family members or guests during drug administration time. At the same time, when new patients come in, it shouldn’t stop anything from happening in the rooms. Emergencies are very important, and even though they can be a distraction, the company needs to find people who will only deal with emergencies. In the same way, people should be given frequent calls and alarm bells so they don’t get distracted during medical treatments or when giving out medications.

Organizational Resources Already in Place

For the growth plan to work, it’s important to look at the organization’s potential, which can be found by looking at the resources it has. Knowledge and skills are two of the tools that could be used. Some of the problems can be solved by using the knowledge and skills that the staff has learned in their training, like making sure that the five rights of the patients are always respected when giving them medicine. Also, the facility’s material tools are important because they will affect how well a plan for improvement is carried out. The resources can be hired from outside the company, but only when necessary, since it’s cheaper to use the resources that are already there.

Conclusion

Root cause analysis and a safety improvement plan are important in every company because they help find problems and figure out how to solve them. Skilled people in a company do a root-cause analysis to figure out what problems need to be fixed first. At Lafayette Villa Nursing Home, problems like the environment, distractions, burnouts, bad communication, drugs with similar names, and confusion caused by similar abbreviations were found to be the reasons of medication errors. After doing a root-cause analysis to make sure the problems found are fixed, you make an improvement plan and a safety improvement plan. Every organization needs to do a root-cause analysis and safety improvement plan on a daily basis because it helps the organization get things done and gives it a competitive edge.

References

Gilani, S. A. (2020). Practices of Nurses in Administration of Safe Medication. I, 18(3), 32.

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., … & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of nursing management, 25(7), 498-507.

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review. The Joint Commission Journal on Quality and Patient Safety.

World Health Organization. (2016). Medication errors. World Health Organization.

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