The healthcare environment is complex because it entails the interaction between different disciplines that depend on each other for a proper outcome of the care delivery. As a result of such complexity, medication errors are inevitable. The problems that come with medication errors are the high rate of death and patient injuries, and this has a negative impact on the hospital and poor quality of services. Therefore, implementing a Root Cause Analysis (RCA) is critical in the hospital as it plays a significant role in reducing the rate at which the medication errors that could lead to death occurs. The root cause analysis (RCA) is a structured process for analyzing the causes of adverse outcomes(Thornton et al., 2014). It is a tool that provides informative highlights of the contributing factors leading to the error that occurred. In the case given, it would have been critical to use RCA to prevent the error in medication that almost killed the patient.
Why RCA Was Critical In the Case
The case presents a good example where different factors interact within the hospital environment leading to an error in medication as the end product. The diagram below is the RCA of what could have caused the incident or wrong medication to happened, and it will help illustrate why having RCA would have been essential in reducing the chances of the error occurring.
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From the diagram, the root of the problem begins on the EMR system itself as it surges forward toward the pharmacist until it reaches a point where the nurse provides the wrong medication to the patient. If the hospital relied on the RCA as described in the diagram, there could have been a positive reaction to curb the problem. First, they could have identified that the ENR system was having some issues with the drug that was being punched in by the nurse because it was not clear from the EMR. It gave several options that were similar and confusing.
Secondly, they could have detected the pharmacist was either incompetent or ignorant because he could adequately verify the drug and also gave a recommendation of its safety. However, the drug was hazardous to the patient. Finally, they could have identified that the nurse was unable to read the label on the medicine as indicated on the EMR, and this led to errors. Therefore, RCA could have stated the pharmacists needed more training, the nurse required to have a team to double-check the drug before admission, and there was a need to update the EMR for proper records.
A tool such as RCA is critical for a hospital as it helps in identifying the root cause of the problem. In this sense, it is essential to reduce the chances of medication errors that could lead to injuries and death. Therefore it enhances patients’ safety and cares in the hospital. Failure modes and effects analysis (FMEA) is a systematic review of failures to study problems that may result from system malfunctions (Thornton et al., 2014).FMEA is a tool that is crucial in studying medical services processes and safety measures. The aim is to ensure that possible causes and areas of failure during the clinical process are avoided by correcting the process, and this enhances the safety of the patients and healthcare provision process (Dastjerdi et al., 2017). Plan-Do-Study-Act (PDSA) is a tool that is critical in verifying a change implementation process. It is a tool that is critical in exposing problems and errors either before they take place, or after they have happened, to prevent their recurrence (Thornton et al., 2014). Therefore, it is a tool that can be critical in exposing errors and mistakes during the healthcare process to enhance the safety of the patients.
Overall, it is critical to ensure that the patients are safe by ensuring that the processes of care delivery are safe and effective. Due to the complexities of the medical environment, errors and mistakes are inevitable in the hospital. It is due to such errors and their impact on the life of the patients that make it advisable for the hospital to implement tools such as FCA, PDSA, and FMEA to reduce the chances of errors occurring.
References
Dastjerdi, H. A., Khorasani, E., Yarmohammadian, M.H., &Ahmadzade, M.S. (2017). Evaluating the application of failure mode and effects analysis technique in hospital wards: a systematic review. J Inj Violence Res , 9(1), 51-60. https://goo.gl/yq9Qxb
Thornton, V.L., Holl, J.L., Cline, D., Freiermuth, C.E., Sullivan, D.T., & Tanabe, P. (2014). Application of a Proactive Risk Analysis to Emergency Department Sickle Cell Care. West J Emerg Med, 15(4), 446-458. https://goo.gl/hMJMys
