Paper Example on Root Cause Analysis (RCA) in Solving Medication Error

Introduction

The RCA is made of a facilitator and members from the process being investigated (Spath, 2013). While the facilitator moderates the meeting through explaining its goal and setting ground rules, the other members provide vital information about the process. In the case scenario, the risk manager is the facilitator while the staff nurse and the pharmacy tech are critical players in the medication administration process. Although the staff nurse at first blamed the pharmacy department for the medication errors, she retracted her statement and agreed to collaborate with the team members to get to the root of the matter (Laureate Education, 2016). Through assessment and improvement of performance in critical areas, the RCA team can eliminate or significantly reduce the medication errors.

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Upon the analysis of records of medication error from the previous year, the team came up with the Pareto chart. The chart is used to isolate significant problems (the vital few) from the others (trivial many) (Spath, 2013). It encourages the use of data instead of perception to determine the most crucial problem. Once the frequency of the problem is arranged, and the cumulative percentage trend line is drawn, the main problem can be identified (Spath, 2013). According to the case scenario, the most prominent issue is defective scanners. Therefore, to avoid errors from this, they should be replaced. Pareto chart is very important to this effect.

The problem mentioned in this case study can be solved. To avoid errors from scanners, they should replace them with the more effective ones. To eliminate mistakes as a result of look-alike medication, they should not be stored nearby (Nicolini et al., 2011). Use of auxiliary labels can also be effective (Jenkins et al., 2007). In general, after the adoption of the abovementioned improvements, the application of Plan-Do-Study-Act (PDSA) or Plan-Do-Check-Act might help in the avoidance of such issues in the future (Spath, 2013). Addition of workforce in the pharmacy department will reduce the stress and unavailability in the pharmacy department. To eradicate knowledge deficit, there should be a policy of sharing information across the departments (Jenkins et al., 2007).

References

Jenkins, R. H., & Vaida, A. J. (2007). Simple strategies to avoid medication errors. Family practice management, 14(2), 41.

Laureate Education (Producer). (2016b). RCA dramatization 1 [Video file]. Baltimore, MD: Author.

Nicolini, D., Waring, J., & Mengis, J. (2011). Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social science & medicine, 73(2), 217-225.

Spath, P. L. (Ed.). (2011). Error reduction in health care: A systems approach to improving patient safety. John Wiley & Sons.

Spath, P. (2013). Introduction to healthcare quality management in nursing (2nd Ed.). Chicago, IL: Health Administration Press.