Root Cause Analysis Discussion

The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient’s assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.

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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 Assignment : Select one tool to analyze.

· 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 (see checklist)

NOTE; This should be a 5-paragraph (at least 550 words) response.

Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old). (Refer to AWE Checklist, Capstone)

Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Chicago, IL: Health Administration Press.

Chapter 4, “Evaluating Performance” (pp. 79-118)
Chapter 5, “Continuous Improvement” (pp. 119-142)
Chapter 6, “Performance Improvement Tools” (pp. 143-174)

Note: Although these chapters are previously assigned readings, please review them in preparation for this week’s material.

Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). St. Louis, MO: Mosby.

Chapter 18, “Leading Change” (pp. 319-335)

https://class.content.laureate.net/a6596733e7b39b81cb24d77c15f22999.html#section_container0

Fishbone_Cause_effect_Diagram.pdf

FISH BONE : CAUSE-EFFECT DIAGRAM

HUMAN FACTORS PHARMACY EQUIPMENT & SUPPLIES

MEDICATION ERRORS

HUMAN FACTORS NURSING

PHARMACY TECH STRESS & BURNOUT

ERROR PHARMACISTS

NEED TO BE ON THE UNIT MORE OFTEN

PHARMACY KNOWLEDGE

DEFICIT: 7 RIGHTS

PHARMACISTS UNAVAILABLE

BY PHONE

SCANNERS FAIL TO SCAN

UNIT DOSE MACHINES ALWAYS

BREAKING DOWN

BARCODE LABELS ARE DEFECTIVE, SCANNERS

CAN’T READ THEM

LOOK-ALIKE MEDICATION

KNOWLEDGE DEFICIT: GENERIC VS. TRADE

NAMES

INADEQUATE STAFFING

KNOWLEDGE DEFICIT: NO RIGHTS OF MEDICATION

ADMINISTRATION

WORKAROUND: MANUAL ENTRY EIN
Pareto_Chart_Medication_Error_Analysis.pdf
Process_Flow_Chart_Medication_Administration.pdf

START

CPOE- COMPUTERIZED

PHYSICIAN ORDER ENTRY

PHARMACY TECH CHOOSES MED OFF THE SHELF

STOCKS UNIT DOSE CART

FOR PATIENT

NURSE CHOOSES MED FROM

UNIT DOSE CART

NURSE SCANS BARCODE

SCANNER SHOWS MATCH

MED ADMINISTERED USING 7 RIGHTS

ELECTRONIC DOCUMENTATION

VIA BARCODE

NURSE DOCUMENTS

ANY REACTIONS

NURSE MANUALLY ENTERS INTERNAL

ENTRY NUMBER

MATCH?

NURSE CALLS PHARMACY

SITUATION CLARIFIED?

NURSE CALLS SUPERVISOR

FOR GUIDANCE

END

PROCESS FLOW CHART: MEDICATION ADMINISTRATION

DOWNTOWN MEDICAL

YES NO

YES NO

YES
DOWNTOWNRCA.pdf

RCA Dramatization 1

RCA Dramatization 1 Program Transcript

FEMALE SPEAKER: Medication errors are a plague. As in the case you’re about to see, it involves a 20-bed medical treatment facility called Downtown Medical. Everyone at the facility had believed that medication errors would decline there for two reasons. First, they started utilizing computerized physician order entry, or CPOE, in conjunction with online nursing documentation, NDMR. And also, they began employing barcoded medication administration. Root Cause Analysis Discussion

But after four years of using these tools, there are still issues. Another medication error has occurred. In fact, there have been many, constituting a significant pattern and trend. So an RCA team has been assembled. The team is comprised of me– I’m the risk manager– Pamela Brown, the staff nurse, and Matthew White, our pharm tech. We called our first meeting. And this is what happened.

This medication error could have easily happened to anyone in our hospital. Our responsibility is to prevent it from happening again. This is the eighth medication error this month. We have to determine the cause of the errors.

FEMALE SPEAKER: I agree, Linda. But if I could be direct for a second, I think if pharmacy got their act together, we wouldn’t be having any of these problems.

MALE SPEAKER: You don’t want to start pointing fingers, Pam.

FEMALE SPEAKER: Look, we’ve all had our share of problems with this issue. And we’re all on the hook for patient safety. We have to get at the root cause of what’s happening here. And that’s why I picked you for this team. I need you to keep an open mind on this.

FEMALE SPEAKER: You’re right. I’m sorry I made that comment, Matt.

MALE SPEAKER: No problem.

FEMALE SPEAKER: The thing is my nurses are always so stressed and understaffed. We hear complaints all the time about patient safety, like it’s all on us. The truth is the pharmacy at Downtown Medical really is quite helpful. I mean that.

MALE SPEAKER: Thank you. What Pam said, the same thing is true in the pharmacy. I’ve been a pharm tech here for 10 years, and it feels like we’re always understaffed. We never seem to have enough people. Maybe we should start by talking about that?

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RCA Dramatization 1

FEMALE SPEAKER: That’s a good idea, but I thought we’d look at the overall process first, from start to finish. Have either of you ever developed a process flow chart?

FEMALE SPEAKER: I’ve read about them. But I’ve never done one.

MALE SPEAKER: Well, I was in on the last IT install. We did process flow charting for that.

FEMALE SPEAKER: OK. So what I thought we’d do is use this first meeting to scope out how the process works. We’ll write it out. After that, you should take it back to your departments and use it to conduct interviews with those who were involved with the actual medication error incident. And then we’ll use it on our next meeting. Is that OK with you?

MALE SPEAKER: Works for me.

FEMALE SPEAKER: Yeah, me, too.

FEMALE SPEAKER: OK. Great. Then the next step will be to identify individuals we’ll want to interview to determine exactly what happened with the medication error. We’ll be constructing a cause effect diagram, which is a qualitative tool done with some brainstorming after the interviews. And we’ll be analyzing last years medication errors as to primary cause. We’ll need weekly meetings and some ground rules to pull this off. Are you game?

The meeting got off to a bumpy start, but once we focused on working together, the RCA team members were true to their word. They kept an open mind and agreed to meet on a regular basis to get the work done. In no time, they helped me complete the process flow chart, a cause and effect diagram, and a complete analysis of a year’s worth of medication errors, which were plotted on a Pareto chart. We were on our way. Root Cause Analysis Discussion

RCA Dramatization 1 Additional Content Attribution

FOOTAGE: GettyLicense_113439900_h12.mov Chayne Gregg/Creatas Video/Getty Images

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RootCauseAnalysis.docx