Implementing RCA to Eliminate Medication Errors

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 safety. Many errors can occur in a healthcare facility related to patient care, and each error should be analyzed using a multidisciplinary team. The team will analyze the sequence of events that led to the error to identify how the error occurred by analyzing active errors and why the error occurred by identifying the latent errors. The teams’ goal is to prevent the error from occurring again.

The healthcare organization has an Automated dispensing machine (ADM) that ensures that nurses can only retrieve the right medication for the right patients. However, to save time, most nurses prefer to use portable medication carts that allow the nurses to carry all the medications for the patients instead of making trips back and forth from the ADM to the patient’s bedside (Billstein-Leber et al., 2018). Portable medication carts are necessitated by having only one ADM in the nursing unit. The medication error the organization was trying to eliminate remains because the risk of a nurse administering the wrong medication increases, especially if they carry medications stored in look-alike vials.

The event involved an overworked nurse who was attending to nine patients. The nurse was in a rush resulting in the administration of the wrong medication to a patient. The ADM dispensed the correct medications for the patients being attended to by the nurse, but the mistake occurred because the vials were stored in look-alike bottles and being in a rush, the nurse did not notice the mistake. The nurse’s concentration was broken due to the amount of work needing their attention. Therefore, the nurse’s focus was impacted, and they did not notice they were administering the 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 occurring in the future.