On the basis of the root cause analysis or RCA, which is “a systematic process for identifying “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop, but finding a way to prevent them” (Washington State Department of Enterprise Services, 2021, para. 2). In order to effectively implement RCA, four primary goals or steps need to be integrated, which revolve around questions, such as “what happened,” “how it happened,” “why it happened…so that,” and “actions for preventing reoccurrence are developed” (Washington State Department of Enterprise Services, 2021, para. 5). In the case of the first step, a patient was given the wrong medication due to the lack of organization and structure around administering medications. The case reveals that there were several major factors, which contributed to the problem.
In the case of the second step, the wrong administration of medication happened because a nurse gave the wrong medication to a patient, which adversely impacted the patient’s health condition. It is stated that the core principles facilitate the concept of Just Culture, which encourages being open about mistakes and errors in order to effectively eliminate them in the future by improving the overall understanding about their occurrence conditions (Skybrary, 2021). The end result was that the patient became unresponsive, which required an immediate transfer to an ICU ventilator. In the case of the third step, the facts include three major factors, which include the patient room location, extra wristbands on the nursing station and the computer on wheels, and carrying several medications on a single nurse. The speculative part involves a possibility that extra wristbands increase the likelihood of inaccurate patient identification, which is further compounded by the presence of a number of different medications in a nurse’s possession. In addition, the location of the patient’s room made it difficult to call a nursing specialist for help after the adverse effects started to take effect.
On the basis of the information presented above, the recommendations and preventative actions should address changing the medication administration protocols by making the process more organized and structured in order to eliminate the possibility of errors. It is stated that “managers must provide the required personal, professional and legal support for nurses to encourage them to effectively report errors, discover the root cause of errors and take measures to prevent them” (Peyrovi et al., 2016, p. 215). Firstly, it is suggested to keep each medication type in a separate location within their assigned boxes. Secondly, a nurse needs to be able to carry only one medication type with properly identified patients, which means that each time the medication is administered, a nursing specialist is consciously aware of the patients requiring them. Thirdly, a nursing station and the computer must not be the place where the wristbands are held, and thus, these items need to be properly placed in their appropriate locations, which are patients’ wrists. Fourthly, the most distant rooms should be checked more regularly than other rooms in order to ensure that patients are safe and in good condition. Therefore, the practical use of these recommendations will mean that each patient receives his or her medications with a higher degree of precision, which will prevent similar errors in the future.
References
Peyrovi, H., Nikbakht Nasrabadi, A., & Valiee, S. (2016). Exploration of the barriers of reporting nursing errors in intensive care units: A qualitative study. Journal of the Intensive Care Society, 17(3), 215–221.
Skybrary. (2021). Just culture. SKYbrary.
Washington State Department of Enterprise Services. (2021). Root cause analysis. Web.