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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 thatanalyze 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 ofmedication errors, which constituted significant pattern and trend, therefore a RCA team wascomprised, consisting of a staff nurse, pharmacy tech, and risk manager (Laureate Education,2016a). Each member of this team can contribute knowledgeable data and information; thepharmacy 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 canprovide the perspective of what is potentially causing the medication error from the clinicalperspective also the medication administration process. The risk manager is evaluating thesafety of the patients involved in the medication errors and the safety of all patients by helpingto prevent further events from occurring. The blame game was initially being played by thenurse; however, before there was any rebuttal, the risk manager was able to jump in andredirect the team back to the root cause, which is the medication errors, encouraging the teamto keep an open mind (Laureate Education, 2016a). The nurse and pharm tech both discussedstaffing 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 ParetoChart. The chart provided the necessary data to understand what the major cause of themedication errors were. The major cause of medication errors was defective scanners, followedby medication labeling that look-alike. According to the Pareto chart, there was O% correlationbetween 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 thefaulty scanners repaired/replaced. Secondly, the pharmacy must come up with a plan to betteridentify pharmacy labels so they will not look identical. This continuous process improvement ofroot cause analysis is described by Yoder as first-order changes, in which is stated that mostquality improvement programs are. This process would benefit from a PDSA to help to eliminatemedication errors to improve patient safety.

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Nursing

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