Introduction
Root cause analysis (RCA) involves identifying the factors that contribute to performance variations. In healthcare, RCA is crucial for preventing medical errors and mitigating their consequences. The Joint Commission mandates all healthcare institutions to have a comprehensive process for systematically analyzing sentinel events. RCA is often the tool of choice for healthcare practitioners in error analysis. The RCA process helps optimize patient care and implement measures to mitigate adverse events that threaten patient safety (Singh, Patel, & Boster, 2022).
RCA will be used for the selected real-life event involving drug mislabeling. The context of the event was a nursing home, a sensitive healthcare setting where errors easily cause fatalities and critical injuries to patients. The event involved a nurse administering 40 units of Levemir instead of 40mg of Lovenox.
The consequence was a drastic drop in the patient’s blood sugar level, and the patient had to be sent to the emergency room. Glucagon was administered to correct the error, and even though the patient survived, the mistake could have been fatal. The error stemmed from poor labeling practices for drugs and other medicines.
Analysis of the Root Cause
The sentinel event for which RCA is conducted is the administration of the wrong medication to a patient. A nurse administered 40 units of Levemir while she was supposed to administer 40mg of Lovenox. The mistake resulted in a drastic drop in the patient’s blood sugar level. The patient had to be rushed to the emergency room and given glucagon.
The nurse observed several signs of low blood sugar, which differed from the anticipated response. Levemir treats high blood sugar, meaning a drop in blood sugar level would be expected after the injection. However, the symptoms of low blood sugar were severe because the patient was not being treated for high blood sugar. The error had a critical impact on the patient, potentially endangering their life. Due to the severity of the symptoms, the patient’s life was saved by administering glucagon in the emergency room.
Incidents of medication errors are common in hospitals and, in some instances, cause serious legal consequences. For example, a recent incident involved a nurse who administered vecuronium to a patient who was supposed to receive Versed (Kelman, 2022). The event made news headlines, and the nurse was charged with reckless homicide and felony abuse. In this case, the impaired patient died, which explains why legal action had to be taken.
Further details of the event include that the nurse failed to take full responsibility and expressed that the fault was not hers alone. Her license was revoked, and as a result, she lost her nursing career. Such events often occur due to careless behavior among nurses, for instance, failing to verify that the medication is correct. Failure to correctly label medicines may also contribute, especially where multiple medications are stored in the same area.
Lack of communication among practitioners may also result in errors, especially when a nurse fails to clarify or confirm the drug to be administered. Other issues in healthcare may also contribute to such errors. For example, burnout and fatigue may cause nurses to lose concentration, leading to serious errors.
Application of Evidence-Based Strategies
Medical errors have been extensively covered in academia and practice due to the potential consequences. The available literature offers viable solutions to medical errors and recommends best practices to mitigate them. Evidence-based practices have also been extensively featured in the literature, with the most common recommendation being the implementation of effective reporting systems.
In essence, error reporting systems are designed to reduce the likelihood of injury to future patients (Al Mutair et al., 2021). Empirical evidence suggests that underreporting medical errors accounts for a significant percentage of the costs per patient. Additionally, underreporting is associated with high mortality rates associated with medical errors. However, reporting systems do not consider preventive mechanisms. Regardless, early warning signals for medical errors can facilitate immediate corrective actions to prevent fatalities.
Various best practices, including adequate drug labeling, can guide preventive approaches. For example, the case scenario provided earlier could have been prevented if the medicines had been properly labeled. Imprints and codes should be distinct and legible to prevent confusion.
The package design should also be clearly differentiated to ensure correct use. For instance, different colors for different drugs could be used to prevent confusion among nurses. Another approach could be labeling medications by intended treatment. For example, syringes and drug containers could be labeled as ‘diabetes treatment’ or ‘high blood pressure’ to help nurses quickly locate the correct medications.
Improvement Plan with Evidence-Based and Best-Practice Strategies
A feasible improvement plan for the case scenario can be designed using evidence-based practices and best-practice strategies. The proposed idea is to use large, colorful stickers on medications to categorize them and prevent similar incidents. For instance, there would be a DIABETES sticker on the Levemir pen and a BLOOD THINNER sticker on the Lovenox syringe/injection.
The current literature provides evidence supporting this plan, indicating that illegible labeling and imprecise dosages can lead to similar errors (Taroq et al., 2023). The desired outcomes of the plan include zero prescription errors, nurses being informed of patients’ illnesses, and always matching patients to the specified treatments. Regarding the milestones, the plan will be implemented immediately, and the nurses will be educated on the new medication labeling system. The hospital is given a week to ensure the new labeling system is implemented and that all nurses have been effectively trained.
Existing Organizational Resources
The medical error emanated from the administration of the wrong medication. The proposed solution entails a more effective labeling system to prevent similar confusion in the future. As a result, the organizational resources required will mainly involve nurses and other professionals involved in prescribing and administering medication. Stickers can be printed or handwritten, but these do not represent a significant organizational resource. The rationale is that the stickers are cheap enough to make the costs insignificant. Additionally, the nurses are already employed by the organization, meaning no extra costs will be incurred.
Conclusion
Medical errors pose a significant challenge in healthcare, particularly for patient safety and the associated legal and financial implications. Medical errors significantly contribute to hospital fatalities, and when the death is averted, it may cost hospitals significant amounts of money to rectify the problem. The available literature discusses evidence-based solutions and best-practice strategies to help resolve the issue.
Effective reporting systems help track errors and facilitate early warning signals for immediate corrective action. In terms of best practices, multiple preventive approaches have been recommended. Examples include more effective labeling systems to help avoid confusion. In the case scenario, such a best practice will involve large, distinct stickers that generalize the medicines. Such a solution requires minimal investment in organizational resources, as stickers are readily available, and hospital staff will undertake the labeling themselves.
References
Al Mutair, A., Alhumaid, S., Shamsan, A., Zaidi, A., Al Hohaini, M., Al Mutairi, A.…, Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 1-12.
Kelman, B. (2022). As a nurse faces prison for a deadly error, her colleagues worry: Could I be next?
Singh, G., Patel, R., & Boster, J. (2022). Root cause analysis and medical error prevention. Tampa: StatPearls Publishing LLC.
Taroq, R., Vashisht, R., Sinha, A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. StatPearls.