Root Cause Analysis

Root Cause Analysis

In the case study, the main aim of composing the RCA team is to find the root cause of the medication errors which have continued to occur despite using the tools of barcoded medication administration and use of a computerized physician order entry utilized in conjunction with the online nursing documentation. The RCA team comprises three individuals: a risk manager, the nurse manager (staff nurse), Pamela Brown, and the director of pharmacy (pharm tech), Matthew White. In medication administration, the nurses and pharmacy departments play a critical role. The nurses have to have knowledge of the types of medicine and how they are branded to ensure that they give the correct medication to the patients. Therefore the nurse manager will be able to explain some of the challenges nurses are facing that could be contributing to the errors made, such as using the online documentation, knowledge deficit, and staffing issues. The director of the pharmacy could also bring in knowledge of the challenges at the pharmacy, which is responsible for dispatching the proper medication. Finally, the risk manager can help conduct assurance to avoid the errors by trying to see how the two departments coordinate and the gaps that contribute to the continuity of the medication errors.

At first, the nurse manager and the director of the pharmacy tended to blame each other for the errors, which brought in diverse and biased opinions. However, through having an open mind in the discussion and agreeing not to blame each other, there can be good communication and collaboration (Lancaster et al., 2015). The RCA team found common ground to discuss the issues with an open mind, enhancing collaboration. For instance, when the risk assurance asks the team to stop blaming each other, Pamela says, “I am sorry I made that comment,” which indicates the willingness to find common ground and focus on the cause of the error than blame each other. After avoiding blaming, the team agrees to work together and conduct regular meetings with agendas spelled out to use various tools to determine the root cause of the problem.

At first, the nurse manager and the director of the pharmacy talked about being understaffed and how being blamed for the medication errors and patient safety demotivates the respective departments. This shows concern on how understaffing is a significant problem that leads to burnout, hence the need to work collaboratively to solve the issue (Swensen et al., 2016). However, the risk assurance officer identifies the need to examine the process flow by trying to create a tool that can help identify how the process works. The first step entails using the team to create a process flow chart and then conducting interviews in the respective departments to identify how the actual medication error incident happened. The findings will be discussed in the next meeting. Secondly, specific individuals will be identified and interviewed about the occurrence of the medication error and develop a cause-effect diagram. In the subsequent meetings, analysis of the medication errors in the previous year will be analyzed in weekly meetings so as not only to solve the current medication error incident but that of the previous year to find the root causes of the medical errors.

The performance improvement chart chosen from the scenario is the Pareto chart used to analyze the medical errors at the Downtown Medical facility. In this case, the chart contained the frequency of the errors on the left vertical axis as well as the specific causes of errors. Therefore, from the chart, an individual could determine two main things, which help determine the cause of errors and possible solutions. First, the chart provides information on challenges in the departments causing the medical errors and can help address those challenges. Secondly, for each challenge, the number of errors associated with it is plotted in a descending order which can help visualize which challenge causes the most errors. In this case, defective scanners cause most of the medical errors at the clinic. Cumulatively, the defective scanners, look-alike medication labeling, and pharmacy tech stress/error contribute to 82% of the total errors at the facility. Therefore, possible solutions should be ensuring that the scanners work correctly or replaced with working ones and maintained. Additionally, the staff could be trained by both the pharmacy and nursing departments on how the labeling is done and how to differentiate those that look alike. There is also a need to evaluate the source of the stress in the pharmacy departments and address it, such as the need to increase staffing. Addressing stress and burnout can help reduce the errors substantially in the future as more interventions are being implemented (Moss et al., 2016).

References

Lancaster, G., Kolakowsky‐Hayner, S., Kovacich, J., & Greer‐Williams, N. (2015). Interdisciplinary communication and collaboration among physicians, nurses, and unlicensed assistive personnel. Journal of Nursing Scholarship, 47(3), 275-284. https://doi.org/10.1111/jnu.12130

Moss, M., Good, V. S., Gozal, D., Kleinpell, R., & Sessler, C. N. (2016). A critical care societies collaborative statement: burnout syndrome in critical care health-care professionals. A call for action. American journal of respiratory and critical care medicine, 194(1), 106-113. https://doi.org/10.1164/rccm.201604-0708ST

Swensen, S., Kabcenell, A., & Shanafelt, T. (2016). Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience. Journal of Healthcare Management, 61(2), 105-127.