Root-Cause Analysis and Safety Improvement Plan
One of the strategies that can help physicians to address safety concerns is learning the root causes of the problem. Root-cause analysis helps to improve services in a healthcare setting by learning the weakness within the institution and putting an effect into addressing the issue. Root-cause analysis aims to identify the initial causal agent of the safety concern to implement the best solutions (Martin-Delgado et al., 2020). The root cause analysis is effective in healthcare because it focuses on the whole process between when the patient enters the hospital to departure. Some factors addressed in the root cause analysis include the tools, chosen approaches, and techniques used to identify the problem. For instance, falls in hospitals could be caused by slippery falls, especially in the intensive care unit, but the patient’s serious health conditions could be blamed. There, looking at all the dynamics surrounding the patient can increase safety. Therefore, this study will address medication prescription errors, measures organizations can take, and develop an improvement plan by understanding the root cause of the issue.
Analysis of the root cause
Several factors cause prescription errors, which should be addressed to improve patient outcomes and reduce healthcare costs. The first root cause of prescription errors is physicians’ lack of caution, especially nurses. Nurses are in charge of medication administration and must ensure they understand the patient’s history. For instance, a nurse should not assume that a patient requires a particular medication because they suffer from a particular disease. Some patients, especially those suffering from chronic diseases, get addicted to medication, harming their immune systems and affecting recovery (Martin-Delgado et al., 2020). Poor communication between the physician and the patient is another root cause of prescription errors. If the patient withholds information from the nurse, the nurse may make a mistake in the administration process. Communication issues can also arise from rushed encounter that prevents the nurse from identifying pertinent information. Lastly, the emergency department records high medication error cases (Martin-Delgado et al., 2020). The emergency department is affected by rushed encounters, serious complications, and urgency to save a life that can attract errors. For instance, a lack of effective medication within the institution can force physicians to use the available medication to address a problem leading to the wrong prescription.
Application of Evidence-Based Strategies
It is important to note that the most effective way of addressing prescription errors is by identifying the root cause. As mentioned above, one of the root causes of medication errors is a lack of caution from the nurses. Although different physicians participate in the patient’s treatment, nurses spend the most time with the patients. Therefore, nurses’ caution plays a significant role in patient safety (Roumeliotis et al., 2019). Education, training, and monitoring can help to maintain nurse competence. Education is important because medication continues to change, and nurses must learn about new medications or new and safe administration techniques. Monitoring is also important to increase patient safety. Monitoring is fundamental for new nurses not conversant with the medication, medication cabin, procedures, and patients (Martin-Delgado et al., 2020). New nurses should learn that their actions have real-life consequences, unlike school practical lessons, to increase caution. Ignorance and negligence within a healthcare facility should be avoided at all costs.
Another root cause of medication error is poor communication between physicians and patients. One of the problems affecting many healthcare facilities worldwide is worker shortage (Martin-Delgado et al., 2020). One nurse may attend to more than a hundred patients daily, like in developing countries, reducing the encounter time with the patient. Therefore, gathering enough information from the patient is difficult, creating room for a mistake. Institutions should ensure they have enough personnel to address a patient’s problems. Institutions should also have policies that create good working conditions for nurses and patients (Roumeliotis et al., 2019). A good environment, such as a positive work interaction, can improve nurse-patient communication. Lastly, nurses working in the emergency department have a high chance of making prescription mistakes. Medication errors in the emergency department can be addressed by adopting technologies to improve data sharing and diagnosis processes. For instance, electric medical records can help nurses assess patient medical information, especially in the case of critical conditions.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The improvement plan to increase medication administration safety is education and training and updating systems within a health institution. The hospital administration should be at the forefront to ensure all stakeholders are safe. The stakeholder, in this case, includes nurse, patients, and other hospital workers (Rodziewicz & Hipskind, 2020). The improvement plan should focus on improving the welfare of all the stakeholders. Education and training will involve nurses because they are responsible for drug administration. The nurses will learn the best practices and strategies to administer medication. Nurse ability to avoid prescription errors can reduce the high cost of healthcare and improve patient outcomes. Nurses should also learn about patients and educate them about the best behaviors and practices to increase medication efficiency. For instance, patients recovering from injury should learn that drinking alcohol puts them at risk. Educating the patient can help address the issue of medication reaction when treating comorbid. Patient awareness about medication can improve adherence and reduce the chances of prescription error.
Next, adopting new technologies in a healthcare facility to improve safety is important. One of the techniques for improving drug administration and safety is telemedicine. Telemedicine allows doctors and other physicians to monitor their patients in the comfort of their space. Telemedicine also allows physicians to communicate and interact with each other even from a distance (Rodziewicz & Hipskind, 2020). Therefore, telemedicine can allow nurses to consult their colleagues or doctors about medication as a caution and safety strategy. Telemedicine also improves efficiency in the emergency department by increasing participation (Martin-Delgado et al., 2020). Telemedicine allows consultation during procedures and increases the number of people ensuring safety on different grounds, including medication. Technologies such as electric medical records help improve communication in the emergency department by analyzing medical history. Therefore, education and training and adopting new technologies can help address the root cause of hospital prescription errors.
Existing Organizational Resources
An organization’s main resource is financial support to enable nurse education and training and buy devices needed to adopt new technologies. The financial ability could be achieved by seeking the government, communities, and interest groups to intervene. The financial resources will help to train nurses by taking them to medical seminars and workshops to gather safety insights (Stehman et al. 2019). The money could also be used to pay for nurse medical loans and further studies to motivate them in their practice and increase caution. The finances would also reward performing nurses to increase motivation and competitiveness in the practices. In addition, the financial ability within an institution can make it possible to acquire new technological resources. The resources include updated computers, high-speed internet, and a good communication channel. New technologies improve various functions within the hospital, including communication, interaction, response, and security.
All the stakeholders within the institution should work together to address patient safety by limiting medication prescription errors. The errors are expensive to the caregivers and patients because they increase the recovery time and resources. Therefore, through root-cause analysis, organizations can adopt education, training, and new technologies to increase caution and awareness in medication administration. Organizations should seek funds from any source to help address the financial demands of education, training, and technological advancement. However, the efforts are feasible and can help increase safety in healthcare.
Martin-Delgado, J., Martínez-García, A., Aranaz-Andres, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of Root Cause Analysis translates to improve patient safety. A systematic review. Medical Principles and Practice, 29(6). https://doi.org/10.1159/000508677
Roumeliotis, N., Sniderman, J., Adams-Webber, T., Addo, N., Anand, V., Rochon, P., … & Parshuram, C. (2019). Effect of electronic prescribing strategies on medication error and harm in hospital: a systematic review and meta-analysis. Journal of general internal medicine, 34, 2210-2223. https://doi.org/10.1007/s11606-019-05236-8
Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2022, May 1). Medical Error Reduction and Prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Stehman, C., Testo, Z., Gershaw, R., & Kellogg, A. (2019). Burnout, drop out, suicide: Physician loss in emergency medicine, Part I. Western Journal of Emergency Medicine, 20(3), 485–494. https://doi.org/10.5811/westjem.2019.4.40970
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