The local hospital had an incident involving the wrong medication administered to a patient. So you have to perform a root cause analysis.
Root cause analysis is a process that is commonly used after an incident has occurred to identify the underlying causes. It has several steps, and the first step is to discover the event, how it happened and why it happened. For an example of a case scenario; the nurse supervisor administered the wrong medication to a child; the medications administered are Solu-Medrol and Depo-Medrol, and the reason for the wrong medication is a lack of staff awareness of the drugs Solu-Medrol and Depo-Medrol since they are rarely used, lack of drug knowledge by the nurse supervisor, poor warning labeling on the product and lack of weekend pharmacy coverage (Dolansky et al., 2013)
The second step is to recommend the stakeholders investigate this case and the reason for involving stakeholders in this investigation. The stakeholders are involved in evaluating the systematic components that may have led to this medication mistakes; During the entire process of collecting data regarding the possible underlying causes, the stakeholders must suggest as well execute instant changes so that a repetition does not happen. They will also explore the risk minimization and process development policies to avoid subsequent medications mistakes from occurring again (Charles et al., 2016)
The third step is to identify the root cause of this problem, compare the five whys of medication administration and how these questions address the root cause, and question one is why the patient received the wrong medication? Poor labeling of the product. Why did the product label wrongly? Because the products were stored beside each other in the pharmacy, why were the products stored beside each other? Because the drugs look alike and the staff lacks familiarity with the drugs. Why did the staff lack familiarity with the drugs? Infrequent use and the absence of the pharmacist who could have helped explain the drug to the nurse. Why was the pharmacist absent? Because the hospital does not provide weekend pharmacy service. The five ways help to identify the root cause of the problem by tracing back to problems that were unclear or obvious (Card, 2017)
The actions were taken due to the error; when the mistake was detected, prompt steps were taken to assess the potential for harm by approaching the children’s hospital and the drug producer: the error was disclosed to the family promptly. The manufacturer was informed of the incident and requested to consider labeling changes and the proposal submitted to provide pharmacy weekend service. The policy change was made to ensure full disclosure of clinically significant mistakes to patients and their families (Dolansky et al., 2013)
In order to avoid medication errors in the future, the following guidelines should be observed: label the drugs correctly, store drugs in labeled containers; save the information leaflets that come with the drugs, ensuring the five rights of medication administration to ensure correct medications are prescribed to correct patient, in the correct passage via correct route and correct time. Have another physician read it back to ensure accuracy. Follow proper medication reconciliation procedures; contemplate using a name alert to stop identical-sounding patients from potential treatment mix-ups, and document drugs administered. Other strategies to reduce medication errors are aware of look-alike sound-alike drugs to avoid confusion, involving the patient to ensure they know their prescriptions and how to take them properly, and lastly, using barcodes; scanning barcodes play an essential role in checking correct drug and dosage form (Charles et al., 2016)
References
Card, A. J. (2017). The problem with ‘5 whys’. BMJ quality & safety, 26(8), 671-677.
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 1-5.
Dolansky, M. A., Druschel, K., Helba, M., & Courtney, K. (2013). Nursing student medication errors: a case study using root cause analysis. Journal of professional nursing, 29(2), 102-108.