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(SOLVED)Root-Cause Analysis And Safety Improvement Plan

(SOLVED)Root-Cause Analysis And Safety Improvement Plan

A systematic approach is often called root-cause analysis to identify the initial causative agent “root cause” of a given medical problem and possible approaches to providing an amicable solution to the problem. The root cause analysis can emphasize established approaches, tools, and techniques for determining the source of a problem. Different root analyses frequently function uniquely toward problem-solving; some approaches are more inclined toward identifying true root causes than others, others are more inclined toward general problem-solving techniques, and others work by supporting the main cause analysis process. For example, an approach based not only on reducing medical administration errors but also on identifying and addressing the root causes of administration errors.

A health facility conducted a root cause analysis of increased medical costs and deaths due to medical negligence and errors in medical administration. The paper illustrates and discusses the causes and consequences of medication administration errors on patient health and the use of evidence-based strategies to reduce medical errors and patient deaths. We are developing a safety improvement strategy using existing organizational resources to address the challenges of medication administration errors (Dolansky et al., 2013).

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Medical administration error root cause analysis

Patient safety and care have long been top priorities in society and policymaking. Nurses are among the healthcare workers affected by medication errors because they administer medications and monitor patient conditions afterward. According to research conducted in the United States, approximately 251,000 patients die yearly due to medication administration errors. Medical administration errors have been linked to disability, large losses, lawsuits, and deaths in patients, family members, and clinicians. The root cause analysis provides sufficient data and analysis aimed at possible solutions for healthcare professionals and patients in understanding and combating medical administration errors, thereby preventing future disability and deaths (Hydari, Telang, & Marella, 2019).

Various concerns about medical administration errors were raised during the 1999 publication of the Institute of Medicine report and news coverage on individuals injured as a result of adverse drug reactions. The joint commission on health care accreditation has also attributed public awareness of medical errors as a cause of increased costs and decreased public confidence in health issues. Most patient injuries caused by drug therapies account for the lion’s share of errors. Nurses and patients are the most affected because they are in charge of drug administration and patient care (Glavin, 2010).

The process of identifying the causal factors that govern variations in health performance is referred to as root cause analysis. Medical error variation is likely to result in sentinel events. The root cause analysis is required to determine the cause of the medical error and develop various strategies to prevent future occurrences.

A combination of factors causes most medical administration errors. They can occur in any medical facility, including hospitals, clinics, medical offices, nursing homes, pharmacies, patient homes, and surgery centers. Medical errors are prevalent in these locations, and a possible solution to the problem must be identified.

Medical personnel or equipment used in inpatient treatment are the most common cause of medication administration errors. According to a study conducted by the backer, one out of every five administered doses resulted in an error. Wrong time accounted for 43% of the errors, omission 30%, wrong dosage 17%, and others 10%. The frequency of medication errors varied depending on the dispensing stage, and each study was classified as incorrect time, incorrect dosage, and omission. 70% of the cases involve prescribing errors, 10% administration errors, 10% documentation errors, 7% medication dispensing errors, and 3% patient monitoring errors following medication administration. Recognizing, preventing, and monitoring medical administration structure is critical in changing healthcare standards to reduce medical error and negligence. The health care system and providers can protect patients’ health and prevent lawsuits by implementing a well-established root-cause analysis to eliminate medical administration errors.

The failure of a system, rather than individual compliance, is often the root cause of medication administration errors, with multiple factors influencing the process. The breakdown in communication between medical personnel and patients is critical. The communication can be informed verbally or in writing. Any medical procedure that is not documented is considered to have been performed on the patient. The handwriting of medical personnel may be difficult to interpret, and the use of non-standardized abbreviations may mislead the medical team, leading to medical errors such as wrong dosage, wrong drug, and drug timing. A good communication system should correctly identify the patient and provide handwritten prescriptions and dosages legibly. To avoid errors, medical personnel should avoid using non-standardized abbreviations in prescriptions, and nurses should indicate when the patient received the drug, the dosage, and when the next dose is due (Abdi et al.,2015).

Long working hours, excessive work, or a complicated medical procedure that does not match the nurse’s experience are all factors contributing to medical errors. As registered nurses were reported to work more than 40 hours per week, such conditions frequently resulted in fatigue and sleeplessness. Medication errors were three times more likely after long working hours and were three times more likely when nurses worked more than 12 hours per shift. Working overtime also increased the likelihood of making mistakes.

The skill mix frequently resulted in medical errors due to challenges such as understaffing medical personnel, a lack of effective equipment, inexperience, and working under adverse conditions. The procedure could be better designed, which frequently leads to medication errors. Other patient-related issues include:
Incorrect patient identification.
A need for more patient education.
A failure to obtain consent for patient treatment.

Based on the root cause of the medical error, the organization should have proposed normal working hours for the patient and ensured the facility was adequately staffed with the appropriate medical procedure and equipment. Nursing should be limited to 8 hours per day, employees should be properly trained, and appropriate structures should be in place to support patient care. Environmental factors such as poor lighting and room temperature can also contribute to medical errors. Because certain drugs are known to be light-sensitive, exposure to light may reduce the desired effect, resulting in underdosing or toxicity. The working environment influences the quality of care in the same way that a poor working environment contributes to medical errors (Huq et al., 2016).

Evidence-based strategies for reducing medication errors

Medical administration errors can be addressed by determining the source of the problem. Most errors were attributed to personal factors, with nurses having the most, as well as environmental and communication factors. Addressing the factors above helps to prevent future medication administration errors. To reduce medication errors, advanced nurses’ practice has been linked to evidence-based practice. The use of education in service aims to improve patient care by providing consistent and organized care.

Medication errors caused by prescribing can be reduced with computerized physician order entry. Tasks and individual factors have also been linked to prescribing errors. The use of computerized physician order entry has largely been electronically linked to other departments such as the pharmacy, reducing medication errors. They implemented a clinical support system to guide drug dosages, frequency, and side effects.

The use of automated dispensers and minimizing prescription illegibility are two features aimed at reducing medication error as a result of dispensing. Also, the use of robots for medication dispensing. To address the personal causes of medical error, it is critical to establish a just culture in the medical field. This is aimed at training and changing behavior to support and consult individuals who are found to be engaging in medical administration errors—removing incentives for offenders and establishing them for those who perform well while also punishing reckless behavior (Mwawule & Bacia, 2019).
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Plan for improvement using evidence-based and best-practice strategies

The improvement plan includes raising awareness about medication errors, educating people about the issues, and improving drug administration technology. When nurses are frequently trained at work and on current emerging trends in patient management, they reduce the incidence of medical errors and improve patient care. The application of technology lessens the human challenges associated with medical errors. Technology can provide a wide range of prescription, dispensing, and drug analyses, as well as the duration of administration, to help prevent medical errors. The system can connect various departments, such as the pharmacy, to reduce prescription challenges. The interval length is determined by reducing medication administration errors (Wong, Levinson, & Shojania, 2012).
Root-Cause Analysis And Safety Improvement Plan

Medical administration errors are the leading cause of patient suffering, death, and astronomical medical costs. Because of their close relationship to patient care and management, medical personnel such as nurses are particularly vulnerable. Poor communication, poor working conditions, personal characteristics, and a lack of adequate knowledge are some of the causes of medication administration errors. The causes of medication administration errors can be greatly reduced by implementing several evidence-based practices aimed at raising awareness and promoting the use of technology in patient care and drug administration.

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