NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

The recent medication error incident at Massachusetts General Hospital (MGH) highlights critical patient safety concerns stemming from communication breakdowns, fatigue among healthcare professionals, and environmental factors. The misadministration underscores the need for robust strategies to prevent such errors. Root cause analysis identifies extended work hours, inadequate hand-off communication, and frequent interruptions as crucial contributors to medication errors. Implementing evidence-based solutions such as Computerized Physician Order Entry (CPOE) systems, Barcode Medication Administration (BCMA) technology, and standardized communication protocols are essential to enhancing medication safety and preventing future errors at MGH.

Analysis of the Root Cause

A recent incident at MGH involved a nurse administering the wrong medication dosage to a patient due to a miscommunication during a shift change. The patient was scheduled to receive 5 mg of a drug, but the nurse administered 50 mg, resulting in adverse effects. The nurse was working an extended shift and was on duty for over 12 hours, leading to fatigue and impaired judgment. Furthermore, the outgoing nurse did not effectively communicate the correct dosage during the hand-off, and the incoming nurse did not verify the medication order against the patient’s records. This error occurred during a peak hour with frequent interruptions from other staff and patient alarms, leading to a lapse in concentration.

Medication errors are a critical patient safety issue in healthcare settings. At MGH, this recent incident necessitated a thorough root cause analysis to identify and address the underlying factors contributing to these errors. This analysis will examine human factors, communication breakdowns, and environmental factors that contribute to medication errors, focusing on the role of nurses and other healthcare professionals. Extended work hours, especially night shifts, contribute to fatigue among nurses, impairing their clinical performance. High patient loads and demanding work environments exacerbate stress and burnout, impacting concentration and increasing the likelihood of errors (Caruso et al., 2022). Inadequate communication during shift changes and patient transfers is a significant contributor to medication errors. Poor communication during hand-offs occurs frequently, leading to errors in medication administration (Chernyak & Posten, 2022). Busy healthcare environments with frequent interruptions pose significant risks to medication safety. Nurses are interrupted frequently while administering medications, leading to distractions and an increased likelihood of errors (Alshammari et al., 2022).

Several evidence-based solutions can be implemented to address the root causes of medication errors at MGH. Integrating a CPOE system with Clinical Decision Support (CDS) can minimize transcription errors and provide real-time alerts for potential medication issues (Karajizadeh et al., 2021). Establishing robust medication reconciliation protocols during all care transitions can ensure accuracy and reduce discrepancies. Adopting BCMA systems can electronically verify medications before administration, reducing the likelihood of errors (Wetzel, 2022). Enhancing education and training is also crucial. Conducting regular training sessions on safe medication practices, effective communication during hand-offs, and promoting a culture of continuous learning through ongoing education and refresher courses can improve adherence to best practices. Creating a safer work environment by implementing “no interruption” zones or periods during critical tasks and reevaluating staffing levels and shift patterns to reduce fatigue and ensure adequate rest for healthcare professionals are also essential (Alshammari et al., 2022).

Application of Evidence-Based Strategies

MGH recognizes the critical importance of addressing medication errors to ensure patient safety. To effectively tackle this issue, MGH will implement evidence-based strategies focusing on leveraging technology and enhancing decision support systems. Integrating CPOE with CDS technology streamlines medication ordering processes, minimizing transcription errors and ensuring accurate prescription orders. Real-time alerts for potential issues such as drug interactions or incorrect dosages empower healthcare providers to make informed decisions, preventing errors before they occur. This strategy enhances accuracy and efficiency in medication ordering, verification, and administration, thereby reducing the risk of errors related to incorrect prescriptions or dosages (Karajizadeh et al., 2021).

Adopting BCMA systems enhances medication safety by electronically verifying medications before administration. Nurses scan barcodes to confirm patient identity, medication, dosage, and route, reducing the likelihood of errors such as administering the wrong medication or dosage. BCMA systems provide real-time error prevention by ensuring medication is administered to the right patient at the right time (Wetzel, 2022). Investing in automated medication dispensing systems equipped with advanced error prevention features reduces the risk of errors caused by manual entry or transcription mistakes. Barcode scanning technology and electronic medication administration records ensure accurate medication dispensing and administration. This strategy streamlines medication management processes, reducing the likelihood of errors caused by manual entry or transcription mistakes (Craswell et al., 2021).

Integrating point-of-care decision support tools into the electronic health record system provides real-time guidance to healthcare providers during medication-related tasks. Evidence-based recommendations, alerts for potential drug interactions or contraindications, and dosing calculators ensure safe and appropriate medication prescribing and administration. This strategy enhances accuracy and efficiency in medication prescribing and administration, ultimately improving patient outcomes (Nanji et al., 2021).

Improvement Plan with Evidence-Based and Best-Practice Strategies

Medication errors remain a pressing concern at MGH, necessitating a comprehensive safety improvement plan. The plan will address various contributing factors, including communication breakdowns, fatigue among healthcare professionals, and technological deficiencies, with evidence-based strategies tailored to enhance medication safety and reduce errors. Implementing standardized communication protocols during patient hand-offs and transitions is foundational to improving information exchange among healthcare providers.

By adopting protocols like the SBAR technique, MGH aims to enhance accuracy and efficiency in information transfer, thereby reducing errors associated with communication breakdowns. Research by Chernyak & Posten (2022) underscores the effectiveness of standardized protocols in minimizing errors during transitions. Furthermore, integrating Automated Medication Dispensing Systems (AMDS) will streamline medication management processes and reduce the risk of errors caused by manual entry or transcription mistakes. AMDS has advanced error prevention features, such as barcode scanning technology and electronic medication administration records, which ensure accurate medication dispensing and administration (Craswell et al., 2021).

Integrating technology solutions such as CPOE with CDS and BCMA systems enhances medication safety. These systems’ real-time alerts and streamlined workflows have significantly reduced errors (Qureshi et al., 2021). By leveraging technology, MGH can enhance accuracy and efficiency in medication administration. Additionally, fostering interdisciplinary collaboration through medication safety committees will enable continuous review of incidents and collaborative interventions. By bringing together nurses, physicians, pharmacists, and quality improvement specialists, MGH can effectively address medication errors and enhance patient safety. Through regular review and collective problem-solving, the committees will drive continuous improvement in medication safety practices (Kozel, 2020). This comprehensive plan underscores MGH’s commitment to providing high-quality, safe patient care.

Existing Organizational Resources

Identifying existing organizational resources at MGH to enhance the patient safety improvement plan addressing medication errors is crucial for effective implementation. Several resources within the organization can be leveraged and prioritized based on their potential impact. MGH can harness the expertise of its clinical staff, including nurses, physicians, and pharmacists. Their frontline experience and knowledge of medication management practices make them invaluable contributors to refining protocols and processes to prevent errors. MGH can benefit from their insights and enhance medication safety practices by engaging them in the improvement plan (Wang & Manskow, 2024). MGH’s health information technology (IT) infrastructure, including the existing CPOE system, CDS tools, and BCMA systems, presents a significant resource. Optimizing these systems to ensure they are user-friendly and seamlessly integrated into clinical workflows can enhance medication management efficiency and accuracy. Real-time alerts and decision support these systems provide can further reduce errors (Heikkinen, 2022).

MGH likely has established quality improvement (QI) teams focused on identifying areas for improvement in patient care and safety. These teams are equipped with expertise in data analysis and performance improvement methodologies. By engaging QI teams in the improvement plan, MGH can effectively analyze medication error trends and implement targeted interventions to address them (Kozel, 2020). Furthermore, MGH’s education and training resources can be leveraged to provide targeted training on medication safety practices. Incorporating medication safety modules into existing training programs and offering regular educational sessions on best practices can ensure that staff remain informed and proficient in medication safety protocols (Alshammari et al., 2022).

Existing interdisciplinary collaboration platforms at MGH, such as regular team meetings or committees, provide opportunities for healthcare professionals from different disciplines to collaborate on patient safety initiatives. By leveraging these channels, MGH can foster teamwork and communication among staff involved in medication management, facilitating the implementation of the improvement plan (Kozel, 2020). By identifying and prioritizing these existing organizational resources, MGH can enhance the effectiveness of its patient safety improvement plan targeting medication errors. Leveraging the expertise of clinical staff, optimizing health IT infrastructure, engaging QI teams, utilizing education and training resources, and fostering interdisciplinary collaboration will collectively contribute to improving medication safety and enhancing patient care at MGH.

Conclusion

Addressing medication errors requires a multifaceted approach that addresses human factors, communication breakdowns, and environmental challenges. MGH is committed to implementing evidence-based strategies such as integrating technology solutions like CPOE with CDS and BCMA systems, establishing standardized communication protocols, and fostering interdisciplinary collaboration. By leveraging existing organizational resources, optimizing health IT infrastructure, and prioritizing continuous education and training, MGH aims to enhance medication safety practices and ensure high-quality, safe patient care. This comprehensive approach reflects MGH’s dedication to mitigating medication errors and promoting a patient safety culture.

References

Alshammari, W. A., Alharbi, S. A., Aldhafeeri, A. M., Aldhafeeri, M. O., Alharbi, S. A., & Aldhafeeri, W. O. (2022). Medication administration time study (MATS): Health professionals performance of medication administration. Chelonian Research Foundation, 17(2), 1522–1530. http://www.acgpublishing.com/index.php/CCB/article/view/472

Caruso, C. C., Arbour, M. W., Berger, A. M., Hittle, B. M., Tucker, S., Patrician, P. A., Trinkoff, A. M., Rogers, A. E., Barger, L. K., Edmonson, J. C., Landrigan, C. P., Redeker, N. S., & Chasens, E. R. (2022). Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector. American Journal of Industrial Medicine. https://doi.org/10.1002/ajim.23363

Chernyak, M., & Posten, C. (2022). Quality of care improvement: A process to standardize handoff communication between anesthesia providers and post-anesthesia care unit nurses. DNP Scholarly Projects. https://digitalcommons.lasalle.edu/dnp_scholarly_projects/2/

Craswell, A., Bennett, K., Hanson, J., Dalgliesh, B., & Wallis, M. (2021). Implementation of distributed automated medication dispensing units in a new hospital: Nursing and pharmacy experience. Journal of Clinical Nursing, 30(19-20). https://doi.org/10.1111/jocn.15793

Heikkinen, I. (2022). Barcode medication administration and patient safety: A narrative literature review. Www.theseus.fi. https://www.theseus.fi/handle/10024/745259

Karajizadeh, M., Zand, F., Vazin, A., Nasiri, M., & Sharifian, R. (2021). Identification and prioritization of clinical decision support functionalities built within a computerized provider order entry system. Health Scope, 10(1). https://doi.org/10.5812/jhealthscope.104607

Kozel, V. (2020). Reducing medication errors through addition of a pharmacist and standardized communication to interdisciplinary team rounding: A quality improvement project. Sigma.nursingrepository.org. https://sigma.nursingrepository.org/handle/10755/20590

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Nanji, K. C., Garabedian, P. M., Shaikh, S. D., Langlieb, M. E., Boxwala, A., Gordon, W. J., & Bates, D. W. (2021). Development of a perioperative medication-related clinical decision support tool to prevent medication errors: An analysis of user feedback. Applied Clinical Informatics, 12(05), 984–995. https://doi.org/10.1055/s-0041-1736339

Qureshi, I., Baig, M. T., Shahid, U., Arif, J. M., Jabeen, A., Pirzada, Q. A., Mirza, A. S., Huma, A., & Toor, M. N. (2021). Computerized physician order entry system: A review on reduction of medication errors. Journal of Pharmaceutical Research International, 27–33. https://doi.org/10.9734/jpri/2020/v32i3931021

Wang, B., & Manskow, U. S. (2024). Health professionals’ experience and perceived obstacles with managing patients’ medication information in Norway: cross-sectional survey. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-023-10485-9

Wetzel, H. E. G. (2022). Barcode medication administration software technology use in the emergency department and medication error rates. CIN: Computers, Informatics, Nursing, 40(6). https://doi.org/10.1097/cin.0000000000000846