Foundation for balanced accountability and patient safety
Foundation for balanced accountability and patient safety
Foundation for balanced accountability and patient safety
COLLAPSE
NURS 4220 Week 4 Discussion Initial Post
The composition of the RCA team consists of a staff nurse, pharmacy technician, and the risk manager to bring together the current focus to assist in medication errors that have taken place for the eighth time within the month. Nursing can bring forth the current challenges that could have contributed to the errors, the pharmacy can bring their expertise to their role in the process of medication administration, and lastly, the risk manager assisting in providing support to both areas to review the facts within the errors and assist in the development of using the Pareto chart for problem-solving (Yoder-Wise, 2019).
Both nursing and pharmacy came to recognize that no one is to blame, instead, a strong commitment to work through the current details that created the errors. Staffing shortages were part of the initial discussion as real challenges for both nursing and pharmacy, but the risk manager wanted to first look at the current events around the medication errors. Nursing started strong with directing blame to the pharmacy, but then took responsibility for not shifting blame as they work to problem-solve together.
All of the possible root causes were pulled from event reports for medication errors that included the reason for the error. There is a list of 12 most common medication errors and of the 12, there were only 7 that resulted from the event reporting. Interestingly enough, staffing was not one of them. The highest of contributing errors 102 was from defective scanning, 60 from look-alike medication labeling, and 60 from pharmacy/tech stress errors. The inability to communicate with the pharmacy resulted in 15 errors. Nursing had a total of 15 errors that were due to unfamiliarity with medication names and five rights.
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The nursing staff can provide a review for the 5 rights for safe medication administration and laminate the 5 rights to each of the workstations on wheels to assist with an easy reference tool for medication administration. With the partnership with the pharmacy, providing the brand and generic name for a drug could assist with unfamiliarity with medication names. When it comes to the support needed from Pharmacy, providing a list of those medications that are not scanning and look-alike medications could reveal trends. It provides a starting point to work from for improvements. One of the more concerning root causes was the 60 errors occurring from pharmacy/tech stress errors.
This would require a deeper dive into those errors to determine if it is a trend with employees, certain times of day, or related to staffing, doing more with less resulting in errors. Starting with a philosophy of a “Just Culture” provides direction that education is first and foremost to provide support to the daily practice (Boysen, 2013). A “Just Culture” suggests that one can learn and grow instead of a culture of penalty or punishment.
References
Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. The
Ochsner Journal, 13(3), 400–406.
Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Chicago, IL: Health
Administration Press.
Yoder-Wise, P.S. (2019). Leading and managing in nursing (7th ed.). St. Louis, MO: Mosby
Chapter 18, “Leading Change” (pp. 319-335).
File NURS 4220 Week 4 Initial Discussion post Johnston D.docx (16.055 KB)
RE: Discussion – Week 4
COLLAPSE
A sentinel event occurred at Downtown Medical as a result of a medication error. A root cause analysis (RCA) team has been assembled consisting of a risk manager, a full-time staff nurse who had the medication error, and a full-time pharmacy technician to determine the medication error (Laureate, 2016b). The risk manager’s role is to motivate the staff nurse and pharmacy tech to contribute their experience and expertise to the processes of discovering the RCA (Spath, 2018). The risk manager re-focused the meeting when staff started to blame each other. She stated the importance of fixing the medication error with an open mind for patient safety. Teamwork is vital to identify all parties’ goals and needs to be involved in producing strategies and outcomes beneficial to the problem under discussion (Yoder-Wise, 2015).
The RCA team began its improvement process by creating a flowchart to establish the steps of administering the medication. Flowcharts allow teams to see the workings of the current process and help the members determine where improvements can be made (Spath, 2018). After the flowcharts were completed, the RCA team members formed a cause and effect diagram to identify why medication errors occurred after CPOE and NDMR processes were implemented. Once the fishbone diagram was complete, and the major causes and subfactors were determined, the RCA team members collected data of medication errors over the last year and constructed a Pareto chart based on the issues identified. Pareto charts help the RCA team to focus on inputs that will have the most significant impact, display data so that it is simple and visually appealing in order of importance, and provides an easy way to compare before and after data to confirm that changes in the process created the desired result (Chartier et al., 2018). The three major causes of medication error were scanner glitches, lack of education regarding generic vs. trade names of medications, and pharmacy technician errors related to stress and burnout. A Pareto chart sorts data from the most frequent to less frequent and places focus on the “vital few” causes an issue that affects eight percent of performance (Spath, 2018).
Identifying these three contributing factors are essential and necessary steps to develop a resolution o eliminate medication errors. Scanners should be repaired or replaced immediately. While nursing staff should always follow the five rights of medication administration. To prevent errors from occurring in the future, the team members need to develop a process improvement plan using a method such as Plan-Do-Study-Act (PDSA) or another model that suits their needs. The team needs to work towards a goal. A team with positive group dynamics tend to trust each other, focus on the issues for improvement, and hold each other accountable to provide quality care and prevent future errors.
References
Chartier, L. B., Cheng, A. H., Stang, A. S., & Vaillancourt, S. (2018). Quality improvement primer part 1: preparing for a quality improvement project in the emergency department. Canadian Journal of Emergency Medicine, 20(1), 104-111.
Laureate Education (Producer). (2016b) RCA dramatization 1 [Video File]. Baltimore, MD: Author.
Spath, P. (2018). Introduction of healthcare quality management (3rd ed.). Chicago, IL: Health Administration Press.
Yoder-Wise, P.S. (2015). Leading and managing in nursing (6th ed.) St. Louis, MO: Mosby
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