Medical errors lead to adverse effects in the field of healthcare production. The errors, mainly generated by medical practitioners are backward and need a quick review to bring quality in the healthcare services offered to patients. Various authors have risen to research and provide a solution to the different types of errors made by the medical practitioners while administering to the patients. It is an issue that needs quick review since human life is at risk for any single mistake made. An investigation by Gorgich, Barfroshan, Ghoreishi, & Yaghoobi (2014) stipulates some causes of medical errors. The authors state that exhaustion due to overworking increased the possibility of errors by 98%. The human body when subjected to long-time tasks without rest definitely will be subjected to fatigue that causes depression of the body and the mind. Another factor by the authors is drug side-effects which stand at 77.4%. The authors recommend a reduction of the workload to ease the effects on the nurses or rather medical practitioners.
The calculation is a critical error identified by Andrew, Salamonson, & Halcomb (2016). When prescribing drugs for patients mathematics knowledge is required by the nurses to give the right dosage. The authors aimed to apply NSE-math to reduce calculation errors in the nursing profession. Even though this totally would sort out the issue of calculation, personal skills are needed to capture the statistics. It will depend on the brain of the nurses undergoing mathematical training. Poor communication is identified as a cause of medical errors (Frydenberg & Brekke, 2012). Patients are usually referred to other levels of treatment at a time when they have already been assigned drugs. The nurses must inform the next level of health administration over the same otherwise the mixture of drugs may contaminate the body of the patient. "The Journal of Clinical Pharmacology" by Benjamin (2001) urge patients to contact the nursing home in case they suspect a disorder from the functionality of medicines provided. Tang FI, Sheu, Yu, Wei, & Chen CH (2007) discusses individual factor and organizational factors as key tenets to the medical errors. Nurses may make mistakes due to their reasons yet organization may also cause the sabotage,
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# |
Analysis Question |
Prompts |
Root Cause Analysis Findings |
Root cause |
Plan of Action |
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1 |
What was the intended process flow? |
List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event. You may need to include multiple processes. Note : The process steps as they occurred in the event will be entered in the next question . Examples of defined process steps may include, but are not limited to: Site verification protocol Instrument, sponge, sharps count procedures Patient identification protocol Assessment (pain, suicide risk, physical, and psychological) procedures Fall risk/fall prevention guidelines |
Frequent contacts with the patients on medication. Interviews with nurses on duty. Keen analysis of the technological tools available in the nursing home for keeping records. Drug prescription methodologies. Nurses' schedule activities personal working hours. |
Yes |
Yes |
|
2 |
Were there any steps in the process that did not occur as intended? | Explain in detail any deviation from the intended processes listed in Analysis Item #1 above. | The personal timetables for nurses were not referenced due to privacy issues. |
No |
No |
|
3 |
What human factors were relevant to the outcome? |
Discuss staff-related human performance factors that contributed to the event. Examples may include, but are not limited to: Boredom Failure to follow established policies/procedures Fatigue Inability to focus on the task Inattentional blindness/ confirmation bias Personal problems Lack of complex critical thinking skills Rushing to complete the task Substance abuse Trust |
High ratio of work overload to nurses. This caused fatigue. Depression from medicine side-effects. Personal problems such as poor calculation skills leading to a calculation error. Inconsistency in drug handling. |
Yes |
Yes |
|
4 |
How did the equipment performance affect the outcome? |
Consider all medical equipment and devices used in the course of patient care, including AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. In your discussion, provide information on the following, as applicable: Descriptions of biomedical checks Availability and condition of the equipment Descriptions of equipment with multiple or removable pieces Location of equipment and its accessibility to staff and patients Staff knowledge of or education on equipment, including applicable competencies Correct calibration, setting, operation of alarms, displays, and controls |
Biometric verification tools used by only authorized nurses. The tools are available in each nursing drug prescribing department. The nursing staff has required knowledge to operate the biometric tools which they acquire by undergoing technological training. Alarms are also availed to increase time-consciousness when a patient is supposed to report to a medical room. |
Yes |
Yes |
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5 |
What controllable environmental factors directly affected this outcome? |
What environmental factors within the organization’s control affected the outcome? Examples may include, but are not limited to: Overhead paging that cannot be heard Safety or security risks Risks involving activities of visitors Lighting or space issues The response to this question may be addressed more globally in Question #17. This response should be specific to this event. |
The security availed at the nursing home keeps all processes smoothly moving. The patients are safe always and the medical machinery is also safe. Generally, the infrastructure is accommodative. |
No |
No |
|
6 |
What uncontrollable external factors influenced this outcome? | Identify any factors the organization cannot change that contributed to a breakdown in the internal process, for example, natural disasters. |
The adverse weather conditions that sometimes denied smooth operations at the nursing home. Family influence from the patients’ place. |
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7 |
Where there any other factors that directly influenced this outcome? | List any other factors not yet discussed. |
Technological advancement. Cultural beliefs. Patients’ preferences. |
No |
Yes |
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8 |
What are the other areas in the organization where this could happen? |
List all other areas in which the potential exists for similar circumstances. For example: Inpatient surgery/outpatient surgery Inpatient psychiatric care/outpatient psychiatric care Identification of other areas within the organization that have the potential to impact patient safety similarly. This information will help drive the scope of your action plan. |
Drug-prescription docket under both inpatient and outpatient care units. |
No |
No |
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9 |
Was the staff properly qualified and currently competent for their responsibilities at the time of the event? |
Include information on the following for all staff and providers involved in the event. Comment on the processes in place to ensure staff is competent and qualified. Examples may include but are not limited to: Orientation/training Competency assessment (What competencies do the staff have and how do you evaluate them?) Provider and/or staff scope of practice concerns Whether the provider was credentialed and privileged for the care and services he or she rendered The credentialing and privileging policy and procedures Provider and/or staff performance issues |
The staff collaborated effectively. They were happy for the application of new mechanisms to cope up with medical error eradication. The process of training was appreciated by the entire nursing fraternity. Especially for the part of calculations which was had been a challenge to most nurses. |
No |
No |
|
10 |
How did actual staffing compare with ideal levels? | Include ideal staffing ratios and actual staffing ratios along with unit census at the time of the event. Note any unusual circumstance that occurred at this time. What process is used to determine the care area's staffing ratio, experience level, and skill mix? | A medical error was contributed to the unfair ratio between a nurse and patients who stood at 1:30. More students are needed to take the nursing career to cover the gap. |
No |
No |
|
11 |
What is the plan for dealing with staffing contingencies? |
Include information on what the organization does during a staffing crisis, such as call-ins, bad weather or increased patient acuity. Describe the organization’s use of alternative staffing. Examples may include, but are not limited to: Agency nurses Cross-training Float pool Mandatory overtime PRN pool |
Staff crisis has always been an issue whenever the number of patients increased. To solve this, agency nurses were called upon to aid in handling patients. Cross-training was also undergoing for flexibility of nurses. Apparently, nurses would double their efforts as they waited for backup. |
Yes |
No |
|
12 |
Were such contingencies a factor in this event? | If the alternative staff was used, describe their orientation to the area, verification of competency and environmental familiarity. | Yes. The credibility of the new staff is highly considered. |
Yes |
No |
|
13 |
Did staff performance during the event meet expectations? | Describe whether staff performed as expected within or outside of the processes. To what extent was leadership aware of any performance deviations at the time? What proactive surveillance processes are in place for leadership to identify deviations from expected processes? Include omissions in critical thinking and/or performance variance(s) from defined policy, procedure, protocol and guidelines in effect at the time. | The staff was competent enough skills were gained appropriately. |
Yes |
Yes |
|
14 |
To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? |
Discuss whether patient assessments were completed, shared and accessed by members of the treatment team, to include providers, according to the organizational processes. Identify the information systems used during patient care. Discuss to what extent the available patient information (e.g. radiology studies, lab results or medical record) was clear and sufficient to provide an adequate summary of the patient’s condition, treatment and response to treatment. Describe staff utilization and adequacy of policy, procedure, protocol, and guidelines specific to the patient care provided. |
The patients' assessment was completed in one week. The nurses aided in the process. Drug prescription was the major tool used to analyze medical error research. Medical records were availed but under the strict supervision of the security department. |
No |
No |
|
15 |
To what degree was the communication among participants adequate for this situation? |
Analysis of factors related to communication should include evaluation of verbal, written, electronic communication or the lack thereof. Consider the following in your response, as appropriate: The timing of communication of key information Misunderstandings related to language/cultural barriers, abbreviations, terminology, etc. Proper completion of internal and external hand-off communication Involvement of patient, family and/or significant other |
Patients communicated with nurses in case they realized the drugs prescribed were not effective. The means of communication included telephone which could be used to access social media platforms. The misunderstandings meant that face to face communication was the best option. |
Yes |
Yes |
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16 |
Was this the appropriate physical environment for the processes being carried out for this situation? |
Consider processes that proactively manage the patient care environment. This response may correlate to the response in question 6 on a more global scale. What evaluation tool or method is in place to evaluate process needs and mitigate physical and patient care environmental risks? How are these process needs addressed organization-wide? Examples may include, but are not limited to: alarm audibility testing evaluation of egress points patient acuity level and setting of care managed across the continuum, preparation of medication outside of pharmacy |
The home environment of the patients symbolized the outcome of medication errors. The proper training the nurses undergone would simply be shattered by family members of the patients who influenced the taking of the drugs. Sometimes when a patient starts getting well before the completion of the dose, the remaining drugs are through away. At the hospitals, the alarm bells at least signal the patients to take their medicines at specified times of the day or rather a night. |
No |
No |
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17 |
What systems are in place to identify environmental risks? |
Identify environmental risk assessments. Does the current environment meet codes, specifications, regulations? Does the staff know how to report environmental risks? Was there an environmental risk involved if it was not previously identified? |
Environmental factors such as weather changes affect the medical error eradication process. In terms of communication, heavy rains adversely affect telephone lines. The proper flow of communication may not be fully solved. |
No |
No |
|
18 |
What emergency and failure- mode responses have been planned and tested? |
Describe variances in the expected process due to an actual emergency or failure mode response in connection to the event. Related to this event, what safety evaluations and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)? Emergency responses may include, but are not limited to: Fire External disaster Mass casualty Medical emergency Failure mode responses may include, but are not limited to: Computer downtime Diversion planning Facility construction Power loss Utility issues |
Every week, the nursing home alert systems are tested and serviced in case of any error. The biometric verification tools are also maintained by IT specialists. Fire extinguishers are also available just in case of a fire outbreak. Ambulances are enough to accommodate emergency calls. Solar energy is available to back up the electric energy. |
No |
No |
|
19 |
How does the organization’s culture support risk reduction? |
How does the overall culture encourage change, suggestions, and warnings from staff regarding risky situations or problem areas? How does leadership demonstrate the organization’s culture and safety values? How does the organization measure culture and safety? How does leadership establish methods to identify areas of risk or access employee suggestions for change? How are the changes implemented? |
The nursing home promotes accountability through is guidelines. The protocol used for reporting risks has been and proven to be working The leadership engages the staff subsequently in meetings aimed at improving the nursing home by eradicating medical errors. The staff must implement the solution after the administration has availed all the required tools. |
Yes |
Yes |
|
20 |
What are the barriers to communication of potential risk factors? |
Describe specific barriers to effective communication among caregivers that have been identified by the organization. For example, residual intimidation or reluctance to report co-worker activity. Identify the measures being taken to break down barriers (e.g. use of SBAR). If there are no barriers to communication discuss how this is known. |
Communication barriers are rare apart from the interference of telephone trains due to heavy rains. |
Yes |
Yes |
|
21 |
How is the prevention of adverse outcomes communicated as a high priority? | Describe the organization’s adverse outcome procedures and how leadership plays a role within those procedures. | The management coordinates with the networking companies to solve the issue of weather barriers to effective communication. |
No |
No |
|
22 |
How can orientation and in-service training be revised to reduce the risk of such events in the future? | Describe how orientation and ongoing education needs of the staff are evaluated and discuss its relevance to the event. (e.g. competencies, critical thinking skills, use of simulation labs, evidence-based practice, etc.) | The staff notably needs critical skills and leadership development skills. The critical skills aid in problem management while the leadership skills aid in running the organization effectively. |
Yes |
No |
|
23 |
Was available technology used as intended? |
Examples may include, but are not limited to: CT scanning equipment Electronic charting Medication delivery system Tele-radiology services |
Yes. The biometric verification tools were effectively used. The database systems deployed for recording and storing data were also utilized. |
Yes |
No |
|
24 |
How might technology be introduced or redesigned to reduce risk in the future? | Describe any plans for implementation or redesign. Describe the ideal technology system that can help mitigate potential adverse events in the future. | Technology is the best solution for medical errors with the emergence of artificial intelligence (AI). The AI technology aims at 100% accuracy. In drug prescription, communication, room allocation, data analysis, and many other functions can be established using AI technology. |
Yes |
Yes |
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Action Plan |
Organization Plan of ActionRisk Reduction Strategies |
Position/Title Responsible Party |
Method: Policy, Education, Audit, Observation & Implementation |
| For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR. … |
Action Item #1: The inadequacy of enough nurses Ratio 1: 30 |
RN, CNA | Education |
| If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time. |
Action Item #2: The network challenge sue to bad weather hence affecting communication |
Network Authority | Audit |
| Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action. |
Action Item #3: Family interference in the dosage consumption by the patients. |
Nursing Home Management | Education |
| Consider whether pilot testing of a planned improvement should be conducted. |
Action Item #4: Technology equipment |
Nursing Home Management | Policy |
| Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented. |
Action Item #5: Organizational influence in the delivery of services to the patients. |
RN | Policy |
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Action Item #6: The calculation challenge experienced to an individual processing capability of a nurse. |
RN | Education | |
| Action Item #7: | |||
| Action Item #8: |
References
Andrew, S., Salamonson, Y., & Halcomb, E.J. (2016). Nursing students’ confidence in
medication calculations predicts math exam performance. Nurse Education Today, 29, 217-223.
Benjamin, D. M. (2001). Reducing medication errors and increasing patient safety through better communication. Focus on Patient Safety. 4, 6-8.
Frydenberg, K. & Brekke, M. (2012). Poor communication on patients’ medication across healthcare levels leads to potentially harmful medication errors. Scandinavian Journal of Primary Healthcare, 30(4), 234–240. https://doi.org/10.3109/02813432.2012.712021
Gorgich C. E, Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2014). The types and causes of medication errors in nursing. Science Road Journal. 8(2), 48–54. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016359/
Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH (2007). Nurses relate the contributing factors involved in medication errors. Journal of Clinical Nursing.16(3):447–457
