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Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a structured methodology for analyzing serious adverse events. According to Wachman et al. (2018) RCA is a quality improvement tool that defines the main problem and identifies the actions necessary to eliminate the problem permanently. The objective is to ensure that the organization does not keep addressing minor symptoms of the problem (Leveson et al., 2020). To avoid fixing minor issues all the time, we should aim at identifying the root cause of a problem and focus on permanently fixing the problem. Determining the true root cause of a problem is difficult. Therefore, an analysis will be done using one or more tools to separate the true problem from the symptoms. RCA allows an organization to determine what happened, why it happened, and how it can eliminate the problem so it does not happen again (Wachman et al., 2018). RCA focuses on identifying the underlying problems that increase the likelihood of problems while avoiding the normal trap of focusing on the mistakes made by individuals. A systems approach is used to identify the active and latent errors (Leveson et al., 2020). RCA is widely used for detecting safety hazards.
A healthcare organization that wants to improve its patient care and outcomes should strive to implement RCA. The quality improvement model allows the organization to identify areas where it is failing and could lead to adverse events and how it can eliminate those errors (Billstein-Leber et al., 2018). The adverse event to address within the healthcare organization is patient...…wrong medication.
RCA can be implemented in the healthcare organization to determine the staffing levels of each nursing unit and the number of patients. The goal should be to identify the underlying problem nurses face when administering medications. For example, it is impractical to force nurses to keep moving back and forth from the bedside to the ADM because it is tasking. The healthcare facility can instead think about using portable ADMs. Healthcare organizations can also petition drug manufacturers to stop using look-alike drug vials whenever possible. Policies should be in place to ensure such errors are avoided. RCA can be implemented to uncover the root cause of the medication error and determine why it happened. Once the analysis is done, the organization will implement solutions to prevent it from…
References
Billstein-Leber, M., Carrillo, C. J. D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY, 75(19), 1493-1517. https://doi.org/10.2146/ajhp170811
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2020). A systems approach to analyzing and preventing hospital adverse events. Journal of Patient Safety, 16(2), 162-167. https://doi.org/10.1097/PTS.0000000000000263
Wachman, E. M., Grossman, M., Schiff, D. M., Philipp, B. L., Minear, S., Hutton, E., Saia, K., Nikita, F., Khattab, A., & Nolin, A. (2018). Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. Journal of Perinatology, 38(8), 1114-1122. https://www.nature.com/articles/s41372-018-0109-8
Medication Errors Since the research materials are provided to you by human beings, and may be based Medication errors pose a significant threat to patients. The results of medication errors vary from mild to deadly. No facility is immune from the possibility to drug errors, either through a fault of their own, or from suppliers or pharmacists that supply them. All medication errors must be reported to the Food and Drug Administration.
Medication Errors Including Look-Alike Sound-Alike Drugs in an ICU People mistakes. This is true in every field and in every job. But in certain areas, mistakes can be costly, even deadly. Medication errors happen because sometimes staff at the medical facility or hospital see drug names that not just look alike, but also sound alike. Statistics point to only 0-2% detection rate of medication errors and prescribing errors. Although over 34%
Medication Errors Over Medication Overmedication can be described as an inappropriate medical treatment that occurs when a patient takes unnecessary or excessive medications. This may happen because the prescriber is unaware of other medications the patient is already taking, because of drug interactions with another chemical or target population, because of human error, or because of undiagnosed medical conditions. Sometimes, the extra prescription is intentional (and sometimes illegal), as in the case
One proven solution to decrease medication errors is use of medication software such as CPOE. It has significantly reduced errors in prescribing, transcription, and dispensing of medications (Hidle). It also has the potential to decrease errors in administration due to unfamiliarity with a drug, drugs with similar names, or incorrect dose calculations since the software performs the calculations. So, why are these systems not used more often in the administration
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