Event: The patient feels excessive drowsiness and thinking difficulties after taking medicine belonging to the benzodiazepines class.
Why did the patient show a strong adverse reaction to taking the drug benzodiazepines class?
The staff exceeded the maximum permissible dose of medication for the patient for the day, and signs of overdose appeared.
Why did the patient receive a larger dose of medication than is acceptable?
In the drug’s dosage description, the criterion ‘as needed’ was indicated, but the specialist did not note the maximum dose.
Why is the chart not contain information on the maximum dose allowed for the patient?
The doctor forgot to indicate information about the maximum permissible dose.
Why did the doctor forget to provide all the necessary information about the medication dosage?
Due to the high load and long shifts, the specialist’s attention may be dissipated, and no additional means may remind the personnel to indicate such information.
Why are no additional measures that may remind the staff to include important dosage information?
There is a necessity for additional means and measures to help the staff stay concentrated on the task and remind them to include all the necessary information about medication.
Action: The hospital needs to add a clause on the maximum dose of the drug to patients’ records. Discussing the modification of electronic health records (EHR) with the information technology team, which is engaged in providing the necessary programs, is required.
Analysis
Medication errors are a common problem for all medical institutions. They affect about seven million patients annually, often with negative consequences for their health (Rasool et al., 2020). Root cause analysis (RCA) is an investigation to solve a specific problem by searching for and eliminating its fundamental causes (McBride & Teitz, 2022). Carrying out RCA is necessary when detecting errors and requires deep analysis to address the problem. Institute for Healthcare Improvement (IHI) (2019) offers many tools for such analysis, one of which is the ‘5 whys’. It helps to identify not just the symptoms of the problem but to find out the key reason to focus.
In the considered case, the nursing home patient showed drowsiness and unusual difficulties in thinking. Such problems are a sign of benzodiazepine overdose, the drug used to reduce anxiety, insomnia, or other disorders (Nordqvist, 2020). The physician forgot to specify the maximum possible dose for the patient, which led to the problem. This type of error refers to memory-based mistakes and is difficult to prevent (Alrabadi et al., 2021). The IHI’s tool ‘5 whys’ allowed for a deeper analysis and focused attention not on the limitations of human memory but on a more effective solution to the problem. Managing EHR with reminder capabilities and additional measures to include complete information can prevent errors (Rodziewicz et al., 2022). The tool gave its advantages in finding the cause of the problem and its solution.
Thus, medical staff should conduct investigations to find opportunities to improve their practice, particularly when identifying errors that threaten the safety of patients. One of the tools valuable to RCA is the ‘5 whys’, involving a sequence of questions to identify the causes of the problem. As the considered example with a drug overdose showed, it helps to identify the symptoms of the problem and its foundations. Consequently, one may offer more practical and concrete ways to address the problem and improve service.
References
Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Farha, R. A., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78-86. Web.
Institute for Healthcare Improvement. (2019). Patient safety essentials toolkit: 5 whys: Finding the root cause of a problem. Web.
McBride, S., & Teitz, M. (2022). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcome, and interprofessionalism. Springer Publishing Company.
Nordqvist, J. (2020). The benefits and risks of benzodiazepines. Medical News Today. Web.
Rasool, M. F., Rehman, A. U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Hassali, M. A. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, 8, 1-7. Web.
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. StatPearls [Internet]. Web.