NURS4220 Week 4 Discussion (1 Completed Essay)
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There are a number of factors that can lead to the cause of an adverse or sentinel event.
The Root Cause Analysis (RCA) is performed by a group safety improvement team members that
analyze the data that determines what were the system deficiencies that led up to the event
(Spath, P. L.). In this week discussion, the scenario discussed the continued problem of
medication errors, which constituted significant pattern and trend, therefore a RCA team was
comprised, consisting of a staff nurse, pharmacy tech, and risk manager (Laureate Education,
2016a). Each member of this team can contribute knowledgeable data and information; the
pharmacy tech can provide the data of the medication errors, the trends (floors, nurses, etc.)
and if the error was nurse made or pharmacy made, such as a transcription error. The nurse can
provide the perspective of what is potentially causing the medication error from the clinical
perspective also the medication administration process. The risk manager is evaluating the
safety of the patients involved in the medication errors and the safety of all patients by helping
to prevent further events from occurring. The blame game was initially being played by the
nurse; however, before there was any rebuttal, the risk manager was able to jump in and
redirect the team back to the root cause, which is the medication errors, encouraging the team
to keep an open mind (Laureate Education, 2016a). The nurse and pharm tech both discussed
staffing as an issue; however, this was not a contributing factor to the medication errors.
The performance improvement chart that I found to be most useful was the Pareto
Chart. The chart provided the necessary data to understand what the major cause of the
medication errors were. The major cause of medication errors was defective scanners, followed
by medication labeling that look-alike. According to the Pareto chart, there was O% correlation
between medication errors and staffing as the pharm tech and staff nurse mentioned.
After performing the root cause analysis, one of the conclusions is to of course to get the
faulty scanners repaired/replaced. Secondly, the pharmacy must come up with a plan to better
identify pharmacy labels so they will not look identical. This continuous process improvement of
root cause analysis is described by Yoder as first-order changes, in which is stated that most
quality improvement programs are. This process would benefit from a PDSA to help to eliminate
medication errors to improve patient safety.
The Root Cause Analysis (RCA) is performed by a group safety improvement team members that
analyze the data that determines what were the system deficiencies that led up to the event
(Spath, P. L.). In this week discussion, the scenario discussed the continued problem of
medication errors, which constituted significant pattern and trend, therefore a RCA team was
comprised, consisting of a staff nurse, pharmacy tech, and risk manager (Laureate Education,
2016a). Each member of this team can contribute knowledgeable data and information; the
pharmacy tech can provide the data of the medication errors, the trends (floors, nurses, etc.)
and if the error was nurse made or pharmacy made, such as a transcription error. The nurse can
provide the perspective of what is potentially causing the medication error from the clinical
perspective also the medication administration process. The risk manager is evaluating the
safety of the patients involved in the medication errors and the safety of all patients by helping
to prevent further events from occurring. The blame game was initially being played by the
nurse; however, before there was any rebuttal, the risk manager was able to jump in and
redirect the team back to the root cause, which is the medication errors, encouraging the team
to keep an open mind (Laureate Education, 2016a). The nurse and pharm tech both discussed
staffing as an issue; however, this was not a contributing factor to the medication errors.
The performance improvement chart that I found to be most useful was the Pareto
Chart. The chart provided the necessary data to understand what the major cause of the
medication errors were. The major cause of medication errors was defective scanners, followed
by medication labeling that look-alike. According to the Pareto chart, there was O% correlation
between medication errors and staffing as the pharm tech and staff nurse mentioned.
After performing the root cause analysis, one of the conclusions is to of course to get the
faulty scanners repaired/replaced. Secondly, the pharmacy must come up with a plan to better
identify pharmacy labels so they will not look identical. This continuous process improvement of
root cause analysis is described by Yoder as first-order changes, in which is stated that most
quality improvement programs are. This process would benefit from a PDSA to help to eliminate
medication errors to improve patient safety.
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Subject
Nursing