Introduction
Improving practice in medical institutions requires constant work analysis, especially of errors. Considering the case under investigation, the event was the administration of the wrong medication. Exploring how the incident occurred, one might assume there was confusion in the medication’s order, prescription, or preparation, or a problem in identifying the patient.
Root-cause analysis (RCA) is required to determine why the event happened. This method is widely used to identify factors that increase the number of errors, helping to concentrate on the primary systemic causes rather than the individuals’ actions (“Root cause analysis,” 2019). Although RCA tools, such as the Five Whys, are easy to use, they improve the safety of medical institutions’ work.
Stakeholders
It is essential to involve the people interested in the RCA in the investigation. Applying systemic thinking, experts understand that many professionals participate in care, and their actions are interwoven (Henry, 2023). All employees who directly participated in the medication’s appointment, order, preparation, and administration should be consulted. They include nurses administering drugs, doctors prescribing and ordering medicines, and pharmacists preparing and transferring prescriptions.
Hospital administration and IT staff are also stakeholders in the considered case. The administration supports the investigation and establishes policies governing employee behavior. The IT department affects the operation of electronic systems used to order medications.
Use of Five Whys
The Five Whys is one of RCA’s techniques to help specify the roots of the problem. Its application assumes that during the analysis of the event, employees will ask the question “why” regarding the incident (Centers for Medicare & Medicaid Services [CMS], n.d.). If addressing the reason highlighted in the response neither solves the problem nor helps avoid the error’s recurrence, it is a contributing factor (CMS, n.d.).
It is necessary to continue using the technique until there is a reason, the elimination of which will help avoid such errors (CMS, n.d.). Therefore, the investigator can ask a different number of questions, more or fewer than five, but each question must contain a clear problem statement (CMS, n.d.). For example, applying this technique to the case under consideration, a potential list of questions and answers can be compiled:
- Why was the wrong medication administered to the patient? The nurse confused two drugs.
- Why did the nurse confuse the drugs? Medicine jars have the same shape and similar labels.
- Why are drug labels similar? The pharmacy does not have a policy or instructions for issuing drug labels.
- Why are there no explicit instructions for the label design in the pharmacy? The organization did not control this issue or pay due attention to this aspect of safety.
By comparing potential questions and answers, one may notice how the focus deepens and shifts from a nurse’s error to a more severe problem, the addressing of which will significantly reduce the risks. Thus, the RCA revealed the issues of culture and organization of work processes in the institution through the Five Whys.
Avoidance of Medication Errors
Medication administration errors can lead to negative implications for patients. Investigation and learning from mistakes to prevent them are critical components of a strong safety culture in healthcare (Barach & Johnson, 2018). Establishing safety protocols and policies that regulate drug ordering and administration can help organizations avoid mistakes.
Using barcodes, special labeling and design for drugs and equipment, and consumer training can significantly reduce risks (Food and Drug Administration, 2019). It is also essential for hospital administrators to maintain a safety culture and provide a working environment for employees, which will allow them to focus on risk reduction. Applying RCA can have significant benefits in achieving safety goals and preventing errors.
Conclusion
Thus, medication administration errors pose a significant threat, and it is crucial to analyze their causes. The investigation may involve several stakeholders, including the patient’s care team, hospital administration, pharmacists, and the IT department. The researcher may use the Five Whys tool to facilitate the search for a cause, which helps focus on the root of the problem. Medication errors can be prevented by establishing a solid safety culture and using additional measures, like barcodes or a specific design.
References
Barach, P., & Johnson, J. K. (2018). Assessing risk and preventing harm in the clinical microsystem. In J. K. Johnson & Sollecito W. A. (Eds.), McLaughlin & Kaluzny’s continuous quality improvement in health care (pp. 235-252). Jones & Bartlett Learning.
Centers for Medicare & Medicaid Services. (n.d.). Five whys tool for root cause analysis. Web.
Food and Drug Administration. (2019). Working to reduce medication errors. Web.
Henry, T. A. (2023). Why you need to be a systems thinker in health care. American Medical Association. Web.
Root cause analysis. (2019). Patient Safety Network. Web.