Science Root-Cause Analysis and Safety Improvement Strategy
Analysis of the Root Causes and a Safety Improvement Plan
The safety concern regarding medication administration in a healthcare setting that must be addressed is persistent medication administration errors caused by treatment management errors. This problem is caused by poorly designed medication administration protocols and a failure to follow the proper guidelines and policies during treatment administration. Medication administration errors have been a persistent issue in the Mayo Clinic healthcare setting, with several inaccuracies recently experienced. Some of these errors included administering the incorrect dose, the wrong medication, and missing doses, the most commonly reported medication administration errors in the healthcare setting (Hammoudi et al., 2018). This paper will review the root-cause analysis of the medication administration error safety issue, the application of evidence-based strategies, the safety improvement plan with evidence-based and best-practice strategies, and the existing organizational resources.
Investigation of the Root Cause
Poor communication between care providers and patients, drug labels that sound similar, and medicine prescriptions that sound similar are all root causes of persistent medication administration and treatment management errors. When administering medication, various errors can occur, including incorrect dose prescription, incorrect time, incorrect drug, incorrect means, exclusion of some dosages, incorrect patient, lack of certification, and methodological errors. There were common medication administration errors at the Mayo Clinic, such as incorrect diagnosis, counseling errors, dose inaccuracies, disastrous drug distribution, observing drug and drug practical associated problems, improper drug management, unsuccessful communication, and a lack of appropriate patient education (Hammoudi et al., 2018). Return clients of the Mayo Clinic healthcare setting identified this issue and filed complaints about the aforementioned medication administration errors. This problem primarily impacted the patients, their families, and the entire community that relied on the Mayo Clinic for healthcare (Koyama et al., 2020). Due to inaccuracies involving missing medications (oversights), duplicate medications, and dosing errors in drug interactions that even worsened the condition of some patients, the issue had a direct negative impact on the patients and their families.
The notable negative effects of medication administration errors on patients included ailment deterioration, insubstantiality, antagonistic medication occurrences, and a prolonged hospital stay. The problem also increased charges when seeking additional medication to improve their condition. While medication administration errors were unintentional, they significantly impacted care seekers and providers; a phenomenon that contributed to some negative mental and adverse expressive effects on the perplexed providers (Koyama et al., 2020). Due to this issue, the patients experienced burnout, lack of attentiveness, underprivileged work enactment, posttraumatic stress disorder, melancholy, suicidality, and rejection (Thompson et al., 2018). Following medication errors, physicians may lose patient trust, civil actions, criminal charges, and medical board discipline. For some patients who were given the incorrect drug route and dosage course, the problem resulted in serious and long-term negative effects and death.
What was expected was a general adherence to guidelines and the provision of dosage prescriptions in medication administration. This would have resolved the problems encountered during drug administration. Given the nature of the problem, it is clear that some steps were skipped, and medication administration to some patients’ care practices needed to be carried out as intended (Keers et al., 2018). Controllable and uncontrollable environmental factors that influenced the issue of medication administration errors included excessive noise levels that disrupted communication between patients and caregivers, inadequate lighting and inappropriate environmental temperature, operational environment principles, and the degree of drug faults that resulted in medication errors (Koyama et al., 2020). Other environmental factors influencing the problem included contamination, pollution, adverse weather changes, some disease-causing microorganisms, a lack of high-quality healthcare infrastructure, and poor service eminence.
The Mayo Clinic’s health care assets and materials, as well as the facilities, personnel, and funds involved in providing health care in the amenity, were resource factors that impacted the problem. Human errors and factors that contributed to the problem included emotional stress in patients and caregivers, a lack of inspiration, a heavy workload, regular deprived communication, and misused patient data stored in information systems, which acted as a causative factor in medication administration errors (Thomas et al., 2017). Listening to and paying attention to the doctor’s prescriptions, the approach used in communication, the patient’s emotional awareness, the use of written communication, and communicating in difficult situations all contributed to the medical administration issue.
The Use of Evidence-Based Strategies
According to previous research, medication administration errors are typically attributed to the failure of traditional treatment management rights (Keers et al., 2018). This includes practices such as not treating the correct patient, administering the incorrect medication, prescribing the incorrect time, and administering the incorrect dose route. These factors have contributed to the safety issue because they involve standard processes for ensuring safe medication administration in the healthcare setting (Stricker et al., 2020). Recent literature has emphasized that medication administration and treatment errors are part of the complex medication process, which involves multidisciplinary teams collaborating to ensure patient-centered quality care delivery (Wen et al., 2019). Medication errors are increased by poor communication and a lack of patient education during medication administration. Strategies can be used to address the medical administration errors safety issue by addressing the existing care gaps that cause medical administration errors (Stricker et al., 2020). The best practices for addressing the issue include implementing standardized communication, providing appropriate patient education, and improving nursing workflow to reduce potential errors.
Plan for Improvement Using Evidence-Based and Best-Practice Strategies
The practices that the Mayo Clinic healthcare setting should implement to address the root causes of the medical administration error problem include the arrangements, new processes, new policies, and professional development that will be implemented to address all of the root causes. Implementing standardized communication principles in the Mayo Clinic Health System will improve patient and caregiver communication principles to ensure the right medication is recommended (Thompson et al., 2018). Furthermore, the shared directives suggest common abbreviations and arithmetic conventions. The administration of appropriate patient education in the healthcare setting will help to reduce the risk of healing management errors (Koyama et al., 2020). This will be critical for all healthcare providers to use the ideal communication approaches and policies routinely provided to patients by education programs, especially when prescription procedures are modified and adapted.
New processes will be in place to optimize the nursing workflow to reduce the possibility of medication administration errors. Distractors during medication administration are common in healthcare settings and are associated with an increased risk and severity of errors (Wen et al., 2019). Minimizing interruptions during medication administration and structuring care checks through consistent workflows will be critical strategies for ensuring medication safety. Some policies, such as the Medicines Act 1968, will be critical in providing the main legal frameworks for medication prescribing and appropriate storage and management of medicines, categorizing them into the appropriate categories (Koyama et al., 2020). This policy is critical because it is the law that governs the administration of medication to patients. The above actions’ goals and outcomes are to improve the status of medication administration, avoid medication errors and interruptions, and prepare medications for patients on time to avoid misperception (Hammoudi et al., 2018). This plan will be implemented over four months, with results assessed at the end of each month.
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Organizational Resources Already in Place
Mayo Clinic Healthcare professionals actively involved in excellence development efforts, such as nurses, medical technicians, physicians, and other medical provision staff, are among the organizational personnel who would aid in the improvement of the plan’s implementation and outcomes (Stricker et al., 2020)… Materials, personnel, funds, and facilities involved in providing quality healthcare services are examples of organizational resources that may be required to ensure the plan’s success (Thomas et al., 2017). As a result, the primary resources in this plan will be human capital (work resources), capital (cost resources), and material goods (material resources).
Medication administration errors are caused by inexperienced individuals recommending, dispensing, giving, and prescribing medications. Medication administration errors have previously resulted in injury and pain for many patients in the United States. However, the vast majority of medication administration errors are avoided. Improving patient education and implementing standardized communication in healthcare are the best practices for preventing medication administration errors. Caregivers, patients, and practitioners’ errors related to low health literacy, deprived patient-provider communication, a lack of health knowledge, and collective precautions are also blamed for this safety issue in Mayo Clinic outpatient instances.