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The Case of Morphine Overdose: RCA and a Qualitative and Quantitative Analysis

Whether triggered by negligence or caused by any other external factors, medical errors affect patients drastically, causing a vast variety of negative results, from minor ones, such as nausea, to lethal cases. Unfortunately, medical errors still occur despite improved services and advanced technology (Siriwardena 156), which the case of Ellie Prudence shows in a very graphic way. To address the issue, the root cause analysis (RCA) must be used and the qualitative and quantitative factors are both to be taken into consideration.

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To organize the RCA team, it will be necessary to define the problem that has emerged. According to the classification provided by Nicolini, Waring and Mengis (“The Challenges of Undertaking Root Cause Analysis” 36), the case can be identified as a medication issue. Therefore, it will be necessary that a nurse, a physician, and, most importantly, a pharmacist should be chosen as the members of the RCA (Nicolini, Waring and Mengis “Policy and Practice” 218). At the beginning of the meeting, the group specified above will be provided with the facts regarding the case in point. Though Nicolini, Waring and Mengis demand that the PA should also be present, seeing how there has been no lethal outcome, there is no need for the PA to be present during the analysis. Distributing the roles and responsibilities of the participants, one must give the pharmacist the task of analyzing the harm done, assign the nurse with checking the medical records and suggest the physician conduct interviews with the family and the nurse that made the injection.

The process of data acquisition is clearly an essential part of the RCA meeting preparation. For the Root Cause Analysis to be exercised efficiently, it will be required to analyze both qualitative and quantitative data (Brown, Smith and Sherfy 14). The latter can be acquired from the reports and receipts. For instance, it will be necessary to check the report statement concerning the amount of the medicine (morphine) that was used to make an injection. The rest of the quantitative data, such as the time when the patient received the shot, the amount of medicine that the patient had taken previously, etc. will be received in the same way, i.e., through the analysis of the existing records. However, apart from the quantitative information, qualitative data will also be necessary for conducting an objective and all-embracive assessment of the problem. Thus, it will also be crucial to conduct qualitative research among those involved in the incident. The latter, in its turn, will be conducted with the help of such a tool as a personal interview and a relations diagram (American Society of Quality para. 9). A very easy, comparatively time-saving and providing opportunity to gain more information about the incident from both the person causing it (i.e., the nurse) and the victims (i.e., the parents), this method is rather effective. In addition, the buddy system will be used to design the methods for avoiding instances of medical errors in the future (“The Buddy System” para. 1). The process of defining information objectivity is going to be especially hard, seeing how the participants are most likely to be very emotional. However, the two tools specified above, i.e., report analyses and interviews, seem to be the most adequate choice at present, with their high speed of data retrieval and the amounts of data that they can provide.

Works Cited

American Society of Quality. Quality Tools. n. d. Web.

Brown, Judy E., Nancy Smith and Beth Sherfy. “Decreasing Mislabeled Laboratory Specimens Using Barcode Technology and Bedside Printers.” Journal of Nursing Care Quality 26.1 (2011), 13–21. Web.

Nicolini, Dabvide, Justin Waring and Jeanne Mengis. “Policy and Practice in the Use of Root Cause Analysis to Investigate Clinical Adverse Events: Mind the Gap. Social Science & Medicine, 73.2 (2011), 217–225. Web.

Nicolini, Dabvide, Justin Waring and Jeanne Mengis. “The Challenges of Undertaking Root Cause Analysis in Health Care: A Qualitative Study.” Journal of Health Services Research & Policy 16.1 (2011), 34–41. Web.

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Siriwardena, Niro A. Using Quality Improvement Methods for Evaluating Health Care. Quality in Primary Care 17.3 (2009), 155–159. Retrieved from the Walden Library using the CINAHL Plus with Full-Text database.

”The Buddy System.” n. d. Vanderbilt Nursing. Web.

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