Nowadays, the primary goals of health care are quality improvement and patient safety. To support medical professionals in performing their work, it is crucial to evaluate potential errors and investigate the imperfections of the system. Root cause analysis (RCA) is regarded as a key tool to determine underlying issues that led to the problem and the changes required to avoid it.
The RCA team of the reviewed case scenario consists of the nurse manager, the director of a pharmacy, and the facilitator, who is a quality assurance person. Each member of the team contributes specific knowledge to the root cause analysis. The nurse provides information about her work, emphasizing the difficulties with scanning the medication’s labels, and reaching a pharmacist. The pharmacist shares difficulties in his work that may cause a burnout error and mentions a lack of knowledge. The facilitator helps them to avoid blaming and focus on identifying the root causes of the error, which is administrating an incorrect medication to the patient.
Some researchers state that “RCAs are typically time-consuming and labor-intensive with a primary goal of producing a report” (Li et al., 2015, p. 495). The case scenario shows that the process might become exhausting even for the participants who are trained to manage root cause analysis. In the case scenario, the collaboration included a description of the difficulties in the work of the nurse and the pharmacist that might lead to a medication error.
It helped the parties to come to the effective solving of the problem. The evidence of effective collaboration is presented in the cause-effect diagram that was produced in the process of the root cause analysis. The diagram shows the bottlenecks of staff and equipment performance. Spath (2013) states that “performance assessment involves judging or evaluating measurement data for the purpose of reaching a conclusion” (p. 65). The diagram shows the data collected during the process of problem discussion. Some of the causes are believed to be bad equipment, defective barcode labels, and the scanner failing to process the delivered medication. The human factors were taken into account as well.
After the identification of performance problems, the causes of insufficient performance should be identified. The team’s process of testing and eliminating the root causes that are not contributing to the problem included identifying the percentage of medication errors for each cause, assessing the risks of its occurrence. Usually, organizations have limited resources, money, and time for improvement projects, and the team has to identify the most crucial issues.
According to Yoder-Wise (2015), “the impact of organization-wide change depends on the organization’s particular stage of development, degree of flexibility, and history of response to change” (p. 326). One of the performance improvement charts presented in the scenario is the Pareto chart of medication error analysis. It helps to identify the root cause assessing the percentage of medical errors for each cause and select the most crucial ones by the high percentage of their occurrence. It also helps to determine the solution to prevent repetitive medical errors by distinguishing the root causes that can be eliminated.
According to the process of testing and eliminating root causes, human factors and lack of pharmacy round were recognized to be the most serious contributing factors of medical errors. Drug administration errors may have serious consequences for the patient. Some researchers advise using Lean Six Sigma methods to improve the efficiency of drug round and prevent such errors. It is noted that “the application of LSS principles enables identification and removal of waste to add value to the patient” (Kieran, Cleary, De Brún, & Igoe, 2017, p. 2). To avoid human factors, it is advised to encourage cell phone communication at the hospital territory.
The reviewed case scenario dealt with the root causes analysis of the problem dealing with the supply of proper medications from the pharmacy, which caused medication errors. The members of the RCA team managed to come to the agreement that the main cause of the problem is the lack of pharmacy rounds. Specific decisions were suggested to prevent medication errors in the future.
References
Kieran, M., Cleary, M., De BrĂşn, A., & Igoe, A. (2017). Supply and demand: Application of Lean Six Sigma methods to improve drug round efficiency and release nursing time. International Journal for Quality in Health Care, 29(6), 803-809.
Li, J., Boulanger, B., Norton, J., Yates, A., Swartz, C. H., Smith, A., & Williams, M. V. (2015). “SWARMing” to improve patient care: A novel approach to root cause analysis. The Joint Commission Journal on Quality and Patient Safety, 41(11), 494-500.
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby.