Introduction
Medical institutions are high-pressure environments characterized by several diverse factors that facilitate confusion and inappropriate service delivery. As a result, medical errors are bound to occur occasionally. However, a root cause analysis (RCA) is a technique that enables nurses to acknowledge the components that contribute to medical mishaps. Understanding the risks involved in particular outcomes enables medical staff to develop effective solutions. The following paragraphs highlight a case study that leads to the death of a patient due to failure to administer medications appropriately. The main factors that contributed to the error were ineffective communication and negligence. Hence, the essay explains how nurses can apply RCA to limit medical errors due to the identified factors.
Analysis of the Root Cause
Healthcare organizations abide by a set of rules to maximize the benefits offered to patients. In some instances, nurses and clinicians may fail to adhere to proposed standards, thus exposing clients to various adversities due to medical errors (Assiri et al., 2018). As such, it happened in the case of Joshua, an 85-year-old resident who was admitted to a nursing home due to a hip fracture. However, he had a history of congestive heart failure and recurring exacerbations.
During his admission, all his vitals were normal and he was given Lasix and Albuterol. However, during his discharge, he was not prescribed or provided with Lasix, which was crucial to managing his condition. The creation of a new Medical Administration Record (MAR) for the patient led to miscommunication. The nurses failed to consult each other and confirm whether all drugs were included in the new list. While transferring information from the old to the new MAR, the nurse mistook the new Lasix order as a duplicate since he saw the initial one on the old MAR and thought it was an update. Therefore, he crossed it out using a yellow line and proceeded to receive a phone call. Later on, the nurse asked a nursing student to complete the task.
The mentioned nursing student then completed the list and deleted the old MAR as required. Subsequently, the nurse passing out the medication noted the yellow line and assumed that the medication had been discontinued. After being returned to the nursing home, Joshua experienced breathing difficulties and a lung assessment suggested moisture and crackles. The ambulance did not arrive in time to resuscitate him, leading to his demise. The clinician responsible for his autopsy noted the error and reported the issue to the hospital and Joshua’s family members. Thus, the event affected Joshua by bringing an end to his life while his family had lost a member. Moreover, the responsible nurses were affected by the court decision, which recognized them as culpable and obliged them to pay compensation to the family of the deceased.
There are several steps that were supposed to occur to prevent the fatal consequence of poor administration. First, the nurse student should have checked to confirm whether the drugs on the new list matched the ones on the old list. Additionally, the student should have inquired the reason why the nurse crossed out the Lasix medication to ensure that he had prepared an appropriate list. Moreover, the nurse responsible for passing out the drugs to patients should have consulted with the clinician responsible for the patient to confirm whether it was right to leave out the drug. Thus, the process required teamwork and collaboration to correct the mistake instead of making assumptions.
Several environmental factors had an influence on the situation. In fact, high pressure at the workplace and numerous obligations in the institution often lead to medication error (Khan & Tidman, 2022). In this case, the workload and responsibilities of the nurses were numerous, which contributed to their dissipated attention and lack of focus, as well as limited their time for communication. In addition, the lack of resources for quick messaging prevented the nursing student from ascertaining the meaning of the yellow crossing and the reasons why the drug was canceled. The human error of forgetting to double-check the medications was, thus, caused by such organizational factors as workplace stress, lengthy hours, and little supervision. The communication factors of emotional distress and environmental distractions have caused the misunderstanding as well. Hence, the root cause of the error was the lack of teamwork and interprofessional collaboration in completing duties and overseeing treatment initiatives caused by stressful and distracting environments and lack of resources for appropriate communication.
Application of Evidence-Based Strategies
Medical practitioners have limitations, mainly because their responsibilities are repetitive and monotonous. The literature suggests that ineffective communication influences adverse outcomes, and specific risk arises when practitioners’ workload includes issues that do not fit their specialty (Khan & Tidman, 2022). However, several strategies could address the issue of miscommunication and human errors caused by it. For example, Irajpour et al. (2019) suggest that interprofessional collaboration and teamwork can notably assist nurses in providing high-quality and comprehensive health services. The proposed strategy can address the problem because it helps service providers to limit errors by facilitating open communication throughout the disease treatment and management processes. Specifically, adopting solutions like databases where practitioners can connect and share data between various departments is helpful (Wheeler et al., 2018). The mentioned strategy can help eliminate avoidable medical errors by assisting clinicians, nurses, and caregivers to work together.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The recommended improvement initiative entails training nurses, caregivers, and clinicians on the tenets of teamwork. Training and education can help practitioners acknowledge the value of collaboration and guide them on the steps to ensure adherence (Assiri et al., 2018). The goal of the training is to inform the staff about how to leverage the knowledge and expertise of other professionals, which could be done in six months. An interconnected and interoperable information system can provide convenient physicians access to hospital data and medication administration records (Khan & Tidman, 2022). The desired outcome of the update is usable communicational technology that medical staff can adopt to deliver health services. The development and implementation of the new system into workflow should be done in two years.
Existing Organizational Resources
The readily available organizational resources for the improvement program include training facilities and interoperable devices like computers and mobile phones. Educating staff members on collaborating in their tasks and sufficiently delivering as expected can help them develop frameworks to deal with medical errors (Khan & Tidman, 2022). Therefore, the organization should seek the services of experts and trainers in the field of interprofessional collaboration. In addition, the institution should leverage the skills of nurse informaticists to improve communication by developing a dedicated information system. These solutions will help improve the organization’s output by taking advantage of open communication and a culture where everyone’s input is required (Irajpour et al., 2019). Time and accurate planning are also critical in ensuring the success of the program.
Conclusion
Medical errors in healthcare are unavoidable and might sometimes go unnoticed if they do not result in adversities. However, a root cause analysis can be used to identify the reasons for particular outcomes and note gaps in medical processes. Medical errors can be severe and ultimately lead to an individual’s death, as in the case study above. Therefore, it is crucial to comprehensively assess the clinical landscape and identify issues that might facilitate errors using a root cause analysis.
References
Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aljadhey, H., & Sheikh, A. (2018). What are the epidemiology of medication errors, error-related adverse events, and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature.BMJ Open, 8(5), e019101.
Khan, A., & Tidman, M. M. (2022). Causes of medication error in nursing. Journal of Medical Research and Health Sciences, 5(1), 1753-1764.
Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in intensive care units. Journal of Education and Health Promotion, 8. Web.
Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business.Australian Prescriber, 41(3), 73.