NURS 4221 Week 4 Discussion
The scenario presented for this week involves conducting a Root Cause Analysis (RCA) at Downtown Medical, a 20-bed treatment facility (Spath, 2013). RCA is a structured process that identifies the underlying factors contributing to an adverse event. In this case, the RCA team was formed due to ongoing medication errors, despite the implementation of computerized physician order entry (CPOE), electronic medical records (EMR), and barcoded medication administration systems. The team consisted of the risk manager, a full-time staff nurse, and a full-time pharmacy technician, each playing a crucial role in completing the RCA. The risk manager facilitated the meeting, collecting and evaluating data while supervising the team members to ensure a blame-free environment. The staff nurse gathered information on medication administration processes, including issues and barriers impacting patient safety. The pharmacy technician contributed expertise in medication filling, dispensing, and the barcode system, as well as insights on the relationship between pharmacy and nursing.
NURS 4221 Week 4 Discussion
During the initial RCA meeting, team members agreed to focus on the problem rather than placing blame, emphasizing collaboration and meeting regularly to identify the root cause and address medication errors for improved patient outcomes and safety.
The RCA team started collecting data by interviewing co-workers in their respective departments to pinpoint communication breakdowns. They then created a deployment flowchart to visualize the optimal process and identify areas for improvement, such as unexpected complications, redundancies, and simplification opportunities (Spath, 2013). Additionally, they employed a fishbone (cause-effect) diagram to investigate the root cause of medication errors persisting despite CPOE and online nursing documentation.
NURS 4221 Week 4 Discussion
Finally, a Pareto chart was used to prioritize contributing factors based on their frequency, highlighting defective medication scanners, look-alike medications, and pharmacy technician mistakes as key issues. The team recognized that defective scanners placed additional work and stress on the nursing staff, leading to potential errors that would be attributed to scanner malfunction rather than human error.
Armed with this information, the team developed an action plan to implement changes and improve performance. Effective teamwork was evident throughout the RCA process, underscoring its critical importance in healthcare. The focus was on improving the system rather than assigning blame, fostering open communication, understanding of roles, and cohesive collaboration (Yoder-Wise, 2015).
NURS 4221 Week 4 Discussion
To ensure future error prevention, the Plan-Do-Study-Act (PDSA) improvement cycle should be considered. This iterative process aligns with the RCA methodology and involves continuously analyzing performance, identifying areas for improvement, and implementing changes to achieve quality objectives (Spath, 2013). By adhering to RCA, PDSA, established ground rules, weekly meetings, and fostering teamwork, Downtown Medical can prevent future medication errors and maintain a focus on quality improvement.
References:
Laureate Education (Producer). (2016b). RCA dramatization 1 [Video file]. Baltimore, MD: Author. Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press. Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Elsevier.
