Name
Capella University
NURS-FPX6201
Instructor’s Name
October, 2024
Root Cause Analysis (RCA)
Medical maloccurrence analysis using Root Cause Analysis (RCA) is crucial in healthcare since it only aims at pointing out systemic susceptibilities to failures that could happen in the future (Ropero et al., 2022). Drawn from a technical background such as engineering or quality assurance, RCA in healthcare concentrates on enhancing patient safety through identifying why errors happened, or why there was a near miss and not proscribing people for mistakes that they made.
This process helps provide visible and tangible accountability and promotes the culture of learning, which is so vital to creating and sustaining improvement in the healthcare sector (Ropero et al., 2022). Thus, RCA enables administrative and medical organizations to pinpoint potential triggering factors including an increased staff load, an absence of some procedures, or disruptive external influence, and enhance care safety, providing healthcare organizations with a practical tool that promotes preventive measures to deliver better and safer patient care while enhancing the resilience and safety culture of a healthcare organization.
The Objective of Root Cause Analysis
This objective comprises establishing patient safety and improving the quality of care by investigating adverse events or near-miss occurrences. By so doing, RCA is aimed at preventing errors at the system level rather than apportioning blame and thereby encourages openness and practical lessons for change (Ziemba et al., 2021). Based on high-reliability organisations this(Blueprint) core aim of RCA is to deliver cause-specific solutions that will in turn help healthcare institutions in putting into practice proven methods of avoiding adverse occurrences (Ziemba et al., 2021). Therefore, RCA helps to promote accountability in healthcare teams to be able to uptake the responsibility within its team to address safety issues and make the healthcare delivery system more robust. RCA can help healthcare organizations consistently tackle mistakes, turning the negatives into benefits to contribute to the creation of better clinical climates.
Case Scenario: Medication Administration Error
A medication administration error is the case scenario under review in this paper in which a patient was administered with the wrong dose leading to severe side effects. Adverse medication administration is among the common adverse events in healthcare facilities and is associated with various risk issues such as incorrect communication, congestion, or even slippage of procedures (Miller, 2022). This will go ahead and show how accurate we have to be, how much attention to pay, and how strictly protocols have to be followed in the administration process.
In this particular case, one of the double-check steps was missed by the healthcare provider by accident and then the patient’s colleague interrupted the process during the procedure (Shah et al., 2022). Studying this case makes it possible to delineate weaknesses in delivering medications, including staffing problems workload distribution, and disruption resulting from environmental factors. RCA of this event can be a route through which healthcare teams can comprehend the context of medication errors and start coming up with specific alternatives for enhanced medication use.
Step 1: Data Collection
The collection of sufficient data is a significant strength of RCA, as this information provides a comprehensive view of the particular incident being reviewed. This medication error involves information such as the description of the prescription, the precise quantity of the drug that was given, the patient’s health status, his medical history, and even any occult circumstances that might have altered the effect of the error (Shah et al., 2022). Cues that include the level of contention, presence of light or darkness during the occurrence of the occurrence,e and the several Healthcare staff involved with the patient portray the exact scenario of the occurrence. Affidavits: team observations, nurses’ notes, and EHR entries or any documented notes regarding a client’s status help to compile a consistent narrative of a case (Miller, 2022). Gathering such robust, multi-source data allows healthcare teams to analyze every factor influencing the incident, ensuring that no underlying causes are missed. By creating an accurate timeline and understanding contributing elements, healthcare providers can more effectively identify and address the error’s root causes, creating a roadmap for safer practices moving forward.
Step 2: Cause Identification Using the “Five Whys” Method
The most widely known method in RCA is called the ‘‘Five Whys,’’ HSEs., is an iterative process that follows a chain of questions to discover the root causes of an incident. In this medication error scenario, asking “why” helps uncover a sequence of interrelated factors: Why was the wrong dosage given? That is why the situation occurred when the nurse was interrupted during the verification of the data (Sluggett et al., 2022). There was an interruption, why was it so? A colleague who recently had to deal with a high-staff workload asked me this question. Why was the workload high? Due to shortages of human resources that would have been required for the development of the software applications.
These questions are asked one after the other until the RCA team finds out that, for instance, there is inadequate staff, or there is no policy that guides control of interferences (Sluggett et al., 2022). The “Five Whys” method shown in Figure 5 identifies a series of factors that contributed to the error: The method illustrates the concept that adverse events more generally stem from system failures rather than individual work errors. Studying these root causes enables various healthcare teams to come up with strong measures that tackle the problem at hand and also strengthen safety measures to avoid a repetition of the same.
Step 3: Contributing Factors
Preconditions are important to investigate because they reveal other aspects of a situation that may worsen the root causes of an adverse event (Jin et al., 2023). In this case, the following sources of contamination were found; excessive noise, poor lighting, and frequent interferences during activities such as drug administration. Moreover, many facilities have one or more patients per nurse, thus making the personnel perform a task rapidly and, therefore risky (Jin et al., 2023). The risk of such errors is compounded by failure in communication especially during handover or while dealing with complicated cases.
There was also inadequate training and noncompliance with protocols for medication administration which should prompt staff renewal on the right medicine handling (Sluggett et al., 2020). Failure to identify these factors contributes to the lack of adequate preventative measures with which healthcare organizations can implement a multi-faceted safety net to reduce the risks in a controlled clinical setting.
Step 4: Recommendations for Preventive Measures
Some of these preventive measures that can be recommended based on the RCA findings include; First, having a system of do-not-discredit signs during activities that can pose a high risk such as administering medicine can greatly decrease the incidence of such incidences (Koyama et al., 2020). a) Forcing the number of patients a single nurse treats within a given time back to reasonable levels would ease workload pressures that hinder the nurse from conducting the critical checks competently. Perhaps, implementing barcoding technology or electronic verification techniques can add an extra layer of protection at the time of giving medications.
It is also important for employees to undergo training that warns of shortcoming that stems from miscommunications and ensure comprehension of safety measures to be taken (Bi et al., 2020). Also, periodic checks of how colors on cabinets and walls appear and noise level, lighting, etc in the medication preparation area constantly guarantee that these areas are safe for practice. In taking such steps, healthcare institutions may go to the root of process and system failure and engender an organizational approach to patient safety hazard identification and eradication.
Step 5: Monitoring and Evaluation
Supervision and evaluation procedures are still important to determine the efficiency of used prophylactic actions. Checklists that are used regularly by supervisors, staff feedback, and normal safety meetings are the major components that assist in determining the effectiveness of new policies (Bi et al., 2020). Heating this, managers and other staff get to see how effective the staff is in observing the “Do Not Disturb” and other safety measures to implement changes where changes are needed.
Recording of incident reports and follow-up of equal RCAs for more recent errors offers continuing information to enhance safety practices., Anti-reporting culture policy also allows staff to come forward and report any possible safety risks within the workplace therefore reducing many incidences that may happen (Liang et al., 2020). In this way, through constant checking of the RCA results after implementing the recommendations, healthcare organizations can guarantee the long-term development of patient safety that supports trust, blame, and everyday improvement of clinical performance.
NURS FPX 6202 Assessment 1 Conclusion
This RCA case demonstrates the use of Root Cause Analysis in enhancing patient safety by providing deeper insights into the root causes of adverse events. A methodical approach to error reporting provides healthcare personnel with information on several intertwined issues like personnel overload, luminiferous interruptions, and step omissions (Sluggett et al., 2020). Analyzing these elements further can help Healthcare teams to determine focused interventions that can help avoid similar occurrences in the future according to RCA. In addition to its inherently corrective purpose, RCA changes the culture in healthcare in a positive way so that providers are motivated and learn from events and incidents that occur while providing care to individuals. RCA therefore plays the dual role of a report card that underscores the commitment of healthcare to quality, effectiveness in averting mishaps, and the very strong emphasis on making perfection a daily practice.
NURS FPX 6202 Assessment 1 References
Bi, J., Yin, X., Li, H., Gao, R., Zhang, Q., Zhong, T., Zan, T., Guan, B., & Li, Z. (2020). Effects of monitor alarm management training on nurses’ alarm fatigue: A randomized controlled trial. Journal of Clinical Nursing, 29(21-22), 4203–4216. https://doi.org/10.1111/jocn.15452
Jin, H., Yao, J., Xiao, Z., Qu, Q., & Fu, Q. (2023). Effects of nursing workload on medication administration errors: A quantitative study. Work (Reading, Mass.), 74(1), 247–254. https://doi.org/10.3233/WOR-211392
Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552
Liang, C., Zhou, S., Yao, B., Hood, D., & Gong, Y. (2020). Toward a systems-centered analysis of patient safety events: Improving root cause analysis by optimized incident classification and information presentation. International Journal of Medical Informatics, 135, 104054. https://doi.org/10.1016/j.ijmedinf.2019.104054
Miller K. S. (2022). Comparing the effects of traditional education and root-cause analysis on nursing students’ attitudes about safety culture and knowledge of safe medication administration practices: An experimental study. Nurse Educator, 47(3), 139–144. https://doi.org/10.1097/NNE.0000000000001126
Ropero, C., González, V. M., Mena, D., Roman, P., Cervera, Á., & Rodriguez, M. (2022). Root cause analysis for understanding patient safety incidents in nursing student placements: A qualitative content analysis. Nurse Education in Practice, 65, 103462. https://doi.org/10.1016/j.nepr.2022.103462
Shah, F., Falconer, E. A., & Cimiotti, J. P. (2022). Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Quality Management in Health Care, 31(4), 231–241. https://doi.org/10.1097/QMH.0000000000000344
Sluggett, J. K., Lalic, S., Hosking, S. M., Ritchie, B., McLoughlin, J., Shortt, T., Robson, L., Cooper, T., Cairns, K. A., Ilomäki, J., Visvanathan, R., & Bell, J. S. (2020). Root cause analysis to identify medication and non-medication strategies to prevent infection-related hospitalizations from Australian residential aged care services. International Journal of Environmental Research and Public Health, 17(9), 3282. https://doi.org/10.3390/ijerph17093282
Ziemba, J. B., Berns, J. S., Huzinec, J. G., Bammer, D., Salva, C., Valentine, E., & Myers, J. S. (2021). The RCA ReCAst: A root cause analysis simulation for the interprofessional clinical learning environment. Academic Medicine: Journal of the Association of American Medical Colleges, 96(7), 997–1001. https://doi.org/10.1097/ACM.0000000000004064
