Medication errors have been a problem in many of the healthcare facilities in the country. Innocent patients have been subjected to the medication error which is not their fault neither do they have nothing to do with it. Medication errors have been in some cases caused the patient to be in a worse condition in addition to the one they had. This essay analyzes a scenario involving the nurse manager and the director of the pharmacy where they are blaming each other for the medication error in Downtown Medical Center (Davis, Drey, & Gould, 2009). The facilitator comes in the action and requests for a Root Cause Analysis instead of blaming one another for the error.
The RCA team that will be involved in this analysis includes the following; number one is the Risk Manager who will be chairing the RCA team because his position is the one responsible for the identification of threats regarding the safety of the patients. The second participant is the RN who works fulltime on the unit since his contribution will be necessary particularly in the provision of the required expertise on the process of administering medication as well as the usage of the barcode medication administration equipment (Slatyer, et al, 2016 p141). The third and the final participant is the Pharmacy Technician who works fulltime in the pharmacy since the person will be required to provide information related to the medication-dispensing machines and how they are filled.
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Using the cause-effect diagram as the analyzing tool, it is clear that human factors such as pharmacy and nursing contributed to the medication error. It is also clear in the scenario that types of equipment and supplies also played a huge part in the error. Drawing evidence from the scenario, it is clear that the pharmacist's knowledge deficits the 7 rights regarding healthcare provision since he ordered for the medication to be administered even after being informed that it is not the correct medication. The provider had also ordered for the medication to be administered after every 6 hours and it is clear that it was not until 8 hours when the nurse was administering the medication which indicates that there is inadequate staffing (Keyko, et al, 2016 p156). And on the types of equipment side it is clear that they failed to scan the medicine. All those factors were the ones that contributed to the medication error. In order to stop this from happening in the future, the health facility should employ enough staff, it should also consider hiring a technician who will be readily available to repair the pieces of equipment and it should also consider having a reliable pharmacist who is qualified to perform their duties.
References
Davis, K., Drey, N., & Gould, D. (2009). What are scoping studies? A review of the nursing literature. International journal of nursing studies, 46(10), 1386-1400.
Slatyer, S., Coventry, L. L., Twigg, D., & Davis, S. (2016). Professional practice models for nursing: A review of the literature and synthesis of key components. Journal of Nursing Management, 24(2), 139-150.
Keyko, K., Cummings, G. G., Yonge, O., & Wong, C. A. (2016). Work engagement in professional nursing practice: A systematic review. International Journal of Nursing Studies, 61, 142-164.
