Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Medication errors are unfortunate realities within the US healthcare system that continues to occur at alarming rates. These events impact all the healthcare stakeholders, including patients, families, healthcare providers, and insurers (Treiber & Jones, 2018). To curb this quality and safety issue, the Joint Commission requires hospitals to occasionally conduct an analysis of sentinel events. One of the commonly utilized processes in the exercise is the root cause analysis (RCA) (Hibbert et al., 2018). Healthcare institutions can optimize patient care through the RCA process and enact measures to mitigate adverse events that compromise patient safety. For example, this easy will review a medication error case involving a 29-year-old female patient treated in an obstetric emergency department. I will employ RCA to identify the root cause of the problem and use the findings to develop a safety improvement plan.

Analysis of the Root Cause

A 29-year-old female at 33 weeks gestation with a history of gestational hypertension presented to the obstetric emergency at midnight with shortness of breath, blurry vision, severe headache, and right upper abdominal pain. She also reported nausea and vomiting in the past three hours. The patient reported the onset of the symptoms to be five hours ago and was associated with a gradual increase in lower extremity edema. The patient is currently taking labetalol prescribed two weeks ago when she was diagnosed with gestational hypertension. Vital takings indicated elevated blood pressure and a significant weight gain since her last check-up five days ago. Diagnostic tests showed excess proteins in the urine and decreased levels of platelets in the blood, indicating a pre-eclampsia diagnosis. The physician ordered IV magnesium sulfate to prevent seizures, injuries to the baby’s brain, and preterm labor by relaxing smooth muscle tissues. The hospital has a standard protocol that requires magnesium sulfate to be administered as 4-gram IV and 10-gram IM regimen in each buttock. The prescription was communicated to the nurse verbally, who prepared it incorrectly due to the rash caused by the urgency of the situation. The poster on magnesium sulfate’s preparation previously placed on the drug preparation room had become faded and had not yet been replaced. Therefore, the nurse relied on her memory during the preparation of the prescription and did not countercheck the medicine with another nurse as per the hospital protocol. Twenty minutes later, the patient started becoming lethargic. She reported severe muscle weaknesses, fatigue, flushing, and dizziness. The attending nurse suspected these to be side effects of magnesium sulfate. She consulted another nurse and repeated the dose strength aloud to her, who crosschecked it from a printed chart and picked up the error in the already administered drug. The case was reported to the senior obstetric resident, who immediately prescribed IV Calcium gluconate, an antidote for magnesium sulfate. She was also put on oxygen therapy and iv fluids.

In this medication error case, several factors contributed to the problem. These include communication deficits among medical staff members, poor implementation of safety and quality protocols, and non-adherence to the implemented protocols by healthcare workers. To start with, the physician verbally provided the order for magnesium sulfate administration to the nurse. Verbal communication of prescriptions poses a significant risk of errors. There is also a deficiency in the hospital protocols regarding the standard protocol through which medications should be communicated. Secondly, the facility management’s poor implementation of safety protocols is evident where the chart displaying magnesium sulfate’s preparation in the drug preparation room had become faded and has not yet been replaced. Therefore, the nurse prepared the medication relying on her memory. In addition, despite standard protocols to countercheck the dose of high-risk medicine, the nurse overlooked the protocol and administered the drug without counter-checking the dose. This indicates poor adherence to the already implemented hospital safety protocols.

Application of Evidence-Based Strategies

Various studies focusing on medication errors have resulted in multiple evidence-based recommendations for addressing the issues. The factors contributing to medication error in the current case can be addressed through evidence-based approaches. Communication deficits among medical staff members can be addressed rough implementation of communication protocols in a healthcare facility (Treiber & Jones, 2018). It is essential to have a standardized protocol for communication among care providers to ensure passing of accurate information regarding patient medication administration. These can hel