Multifactorial-Medication MISHAP RCA
Student name;
Course;
Instructor;
Date;
A Root Cause Analysis (RCA) is appropriate and beneficial in this case study since the established cause of a drug mistake is not just the responsibility of an individual working within the large and complex drug use cycle (Schafer, 2012, p. 8). Application for RCA in the case of medication error involving a 50-year-old man who has been recovering from spine surgery will help determine what was wrong and how well the problem can be fixed. In most cases, the mistake in drugs is one of the main factors that influence drug use. These major elements mutually reinforce the drug use process; prescription of drugs, preparation of orders requirements, the dispensation of the drugs, administration of drugs to the patient, and finally, monitoring the patient progress. In this case, the pharmacist retrieved, labeled, and presented the drug and the calibrated syringe to the bedside nurse to explain that this concentration was a higher dose prescription. RCAs could be essential for its applicability in post-events, especially when adverse events happen in the healthcare setup. In a certain scenario, the nurse should double-check medication requirements with another practicing professional before administering the medication. In this paper, I will address possible effects on patient care quality and safety using recommended resources such as RCA, PDSA, and FMEA.
In enhancing patient care, RCA’s factors are commonly used methods in the health care field. Double-checking requirements for RCA ensures that a significant number of mistakes are reported in the process of prescribing, dispensing, administration of the medication (Schafer, 2012, p. 4). Even though the RCA mechanism is reliable, its ineffectiveness due to; inadequacy in educational strategies and measures of implementation of available policies, failure to integrate data through agencies, and failure to provide prior error detection, limits its applicability. The mistake would have been prevented by not supplying this medication in the individual dose of the syringe.
Failure Mode and Effects Analysis (FMEA) is another tool applied in the health care field proactively before an event occurs (Subriadi et al., 2018, p. 4). Evaluations are majorly done on potential failures and errors in the system of a health care setting. Procedures in FMEA identify and predict any weakness in the system, and in reaction, it makes changes meant to minimize or avoid any harmful effects. Although FMEA is helpful, it is a time-consuming procedure that requires a multidisciplinary collaboration equipped with a strong understanding of the particular mechanism being studied. For effectiveness, the company should implement designed policies and also rely on professionals’ diligence.
Plan-Do-Study-Act (PDSA) cycles are another process that provides a framework for adaptive testing of any changes to boost quality systems (Slootmans, 2017, p. 7). This method provides a mechanism in which suggestions are made on making a change, implementing it, and how the change will be applied considering the benefits of the change. This method is considered when one needs to evaluate whether to work with a certain idea or not. In this case, the error could have been prevented using this method for the six rights of medication administration that could have been applied. This is an ongoing process where suggested changes would be of benefit in improving patient care.
In applying the three methods of analyzing, preventing, and keeping change, health care practitioners can have a better and safer way of providing quality care to patients. A positive patient outcome can be achieved by being proactive and vigilant while making suggestions for change. In an event where there is a mistake in drug administration, it is equally important to evaluate the problem’s cause and possibly fix it to protect the patient. It is the nurses’ responsibility to help the patient recover and provide safety in the care process.
References
Schafer, J. J. (2012). A root cause analysis project in a medication safety course. American Journal of Pharmaceutical Education, 76(6), 116. https://doi.org/10.5688/ajpe766116
Slootmans, S. (2017). Project management and PDSA-based projects. The Organizational Context of Nursing Practice, 175-198. https://doi.org/10.1007/978-3-319-71042-6_8
Subriadi, A. P., Najwa, N. F., Cahyabuana, B. D., & Lukitosari, V. (2018). The consistency of using failure mode effect analysis (FMEA) on risk assessment of information technology. 2018 International Seminar on Research of Information Technology and Intelligent Systems (ISRITI). https://doi.org/10.1109/isriti.2018.8864467