Root-Cause Analysis (RCA) and Safety Improvement

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Table of Contents

Evidence-Based Strategies to Address the Sentinel Event
Safety Improvement Plan for Safe Medication Administration
Improvement Plan
Conclusion
References

A medical mistake is an inconvenient truth of the healthcare business and a subject that is constantly debated due to its devastating influence on clinical outcomes. Medical mishaps typically occur due to a strategy being executed incorrectly or a means of execution being planned poorly (Charles et al., 2017). Medication mistakes can also happen during preventive healthcare procedures, such as when a clinician fails to consider a client’s allergy when delivering treatment. Thus, the sophistication of a misdiagnosis can vary significantly and express itself in any phase of treating patients, from admittance to release and outpatient treatment (Charles et al., 2017).

For example, a case study scenario in a nursing facility where a client was diagnosed with nausea and vomiting symptoms and was administered with doses of pegfilgrastim but should have received filgrastim. While both drugs are given via injection and are designed to increase the formation of white blood cells, the prescription filgrastim can be used daily. Unfortunately, the victim died eleven days later at the care setting after repeated administrations of pegfilgrastim. In addition, the client developed respiratory intoxication due to acute severe lung injury. A more traditional approach would have concentrated on personal guilt by blaming the physician who diagnosed the patient for the treatment despite the absence of a consent document.

However, the successive RCA identified various errors within the organizational characteristics, such as the diagnostic section’s susceptible scheduling methodology that recognized ailments by onsite checks rather than comprehensive diagnostic checks. Other contributors included contextual work parameters, such as the nurse who alleged the mistake but did not consult with colleagues since multiple diseases present symptoms of nausea and vomiting.

Therefore, this prompted the institution to institute a sequence of structural alterations to minimize the possibility of another similar blunder occurring in the future. Numerous orthopedic initiatives, groups, and commissions have been established to assess healthcare outcomes and prevent potential clinical complications. Comprehensive root cause assessment and remediation have grown in popularity. When properly conducted, RCA reduces operational mistakes across a wide variety of specializations.

Evidence-Based Strategies to Address the Sentinel Event

Poor diagnostic within medical institutions has been a prevalent issue in healthcare. An emphatic body of research has revealed that the client medical data storage process is complex when individuals lack understanding on which concerns to address, whom to contact when their situation evolves, and what comprises severe symptoms (Pelaccia et al., 2020). Additionally, it is uncertain who is accountable for handling the loop on medical reports and recommendations and communicating follow-up (Pelaccia et al., 2020). Patients and clinicians feel emotionally pressured by hospital appointments, which jeopardizes the ability to acquire a detailed examination for assessment and leaves little time to address subsequent stages in the testing process.

Systems can aid in the reduction of pharmaceutical errors in hospitals. Several instances include electronic medical records, barcoding systems, standardized units of measurement, eliminating misleading units of measurement, weight-based administration, and having a pharmacist on hand to assist with dose calculation. It is crucial to examine medicine and dose before delivery to minimize unnecessary pharmaceutical errors. The use of barcodes and portable electronic tools improves the safety of medicine delivery. By offering meaningful patient data, medication histories, laboratory readings, drug data, and recordkeeping, errors can be minimized.

Electronic drug administration enables the identification of erroneous and omitted medications and canceled or altered medication orders. By evading barcode processes, you reduce the level of protection at the transitions of service. Pharmacy automation technologies that make medications immediately accessible to patients at the delivery of access free up physicians and caregivers to perform other safety-related tasks, such as medication management.

Furthermore, EHRs have improved health through promoting better health throughout the society, including cardiorespiratory fitness, improved diet, minimization of behavioral concerns, and enhanced use of primary care. It also increases efficiency and cost savings in health care by encouraging preventative treatment, improving service synchronization, and minimizing waste and redundant tests (Marmor et al., 2018).

EHRs also play a significant role in improving clinical decision-making by integrating patient data from numerous sources (Marmor et al., 2018). Additionally, telehealth is another option for enhancing effective patient records collaboration and enhancing the overall quality of health care (Graber et al., 2017). Appropriate expert consultation is necessary for a correct diagnosis. Interruptions and the inability to secure specialist consultations have been attributed to inadequate recordkeeping, which telemedicine and electronic documents can assist in addressing (Graber et al., 2017). Telehealth has been highly successful in facilitating access to ophthalmic professionals to diagnose macular degeneration (Graber et al., 2017). Teleradiology is another remarkable success story in treatment, enabling an around-the-clock supply of qualified professionals.

Safety Improvement Plan for Safe Medication Administration

There are evidence-based medical approaches for various illnesses, including bronchitis, irregular heartbeat, and hypertension. However, these norms are not always adopted in healthcare provision, and there is considerable diversity in implementation. Historically, patient safety studies have focused on a data assessment to examine patient safety concerns and demonstrate that a significant advancement will increase patient safety and productivity.

Numerous aspects of translation studies are instructive for enhancing patient security measures. First, assessing the environment and involving point-of-care healthcare practitioners in selecting and prioritizing patient safety programs, explicitly articulating the documentation foundation for patient safety challenges and the circumstances or settings they apply (Amit-Aharon et al., 2020). These engagement strategies must be specifically designed and tailored to the specific user groups of each participant.

Second, demonstrate why the institution and its employees should use qualitative or quantitative data to adhere to an evidence-based security management topic, such as sentinel incidents, serious incidents, and losses from potential complications (Amit-Aharon et al., 2020). Third, academic instruction alone can never influence behavior; a one-time teaching session on a safety awareness effort will never suffice. Increased understanding does not always result in an improvement in practice (Amit-Aharon et al., 2020). Rather than that, healthcare institutions must spend the resources and personnel necessary to foster an environment conducive to evidence-based patient safety precautions, where inquiries are appreciated, and processes are in place to make doing the right thing simple.

Lastly, it is critical to analyze the methodologies and consequences. Customers and partners must understand that attempts to increase clinical outcomes have a beneficial effect on service delivery (Amit-Aharon et al., 2020). For instance, if a revolutionary barcoding technology is being utilized to deliver blood transfusions, it is critical to ensure that all procedural stages are completed (Amit-Aharon et al., 2020). The alteration in practice leads to fewer blood product transfer mistakes.

Improvement Plan

Mandatory Reporting Systems

In healthcare institutions, safety measures are in place to protect people, their relatives and caregivers, medical professionals, contract service employees, activists, and the numerous other people who transactions them into contact with a clinical setting. Safety is one part of quality, which encompasses avoiding unnecessary injury and having the best possible care accessible to people who need it by giving adequate care to those who may profit from them and eliminating ineffective or dangerous treatments.

The term mandated reporting systems refers to reporting structures whose ultimate focus is to make care providers liable. The primary focus is the reporting of errors that result in serious harm to individuals. National regulatory agencies administer the majority of obligatory reporting standards with the capacity to investigate particular instances of noncompliance and impose fines or sanctions. These approaches serve three objectives.

First, they safeguard the public by ensuring that the most egregious errors are disclosed and scrutinized, as well as taking appropriate corrective action. Second, they motivate health care companies to enhance patient safety to prevent causing punishments and press attention. Lastly, they force all health care institutions to invest in consumer health to some extent, leveling the competitive landscape. While safety professionals acknowledge that mistakes resulting in significant injury are the base of the iceberg, they constitute a tiny percentage of failures that suggest systemic failures with severe repercussions for consumers.

Therefore, mandatory reporting mechanisms should prioritize identifying major severe events caused by error. Adverse occurrences are defined as fatalities or significant injuries that occur as a result of a medical procedure. Not all bad occurrences are caused by errors, although a significant proportion of them are. For two reasons, mandatory compliance programs typically force health care institutions to file data on all significant adverse events: they are easy to detect and difficult to falsify. From the scenario discussed within the essay, having a mandatory reporting system within the organization would help reduce incidences of negligence among clinicians to prevent causing severe harm to patients. Since nurses are aware of the repercussions of avoiding care, medication errors would reduce.

Existing Organizational Resources

Some of the existing organizational resources that may necessitate implementing the safety improvement plan discussed above include institutional finances, dynamic resources, and safety and security systems. The security fiber network is responsible for securing the institution or facility’s functional departments and guaranteeing customers, staff, and visitors’ safety, order, and moral fortitude. These measures provide a lean platform for installing a mandatory report improvement plan within medical facilities. Furthermore, since individuals monitor them, medical errors are quickly detected upon incorporating the improvement plan in the care institution’s system.

Safety and Security Systems

Established norms within hospitals should encourage and promote a norm of protection, civil defense, self-defense, and order, in which consumers and property are protected and kept secure. An organization’s security and safety resources aid in implementing the obligatory report mechanisms to help detect and report medical mistakes. Therefore, firms should project a sense of security by adhering to contractual obligations and applicable regulations.

Dynamic Resources

Capabilities allude to an institution’s ability to carry out a synchronized set of actions while leveraging corporate resources to accomplish a specific goal. Capabilities are founded on practices or how things are typically done in an enterprise (Evans et al., 2017). Core competencies are a subset of abilities that are preoccupied with resilience. Dynamic capabilities explain how healthcare settings improve and sustain effectiveness despite the constantly shifting contexts by expanding, adapting, or creating new resources through expenditure and other administrative initiatives.

Additionally, dynamic capacities have been defined as a resource and routine versatility and adaptation. According to the idea of the open system, businesses must be both robust and adaptable enough to continue producing value in their unique way (Evans et al., 2017). Evans et al. (2017) distinguished specific sets of dynamic resources as responsive capability, which identifies and capitalizes on emerging trends, and absorbent abilities, which absorb new information and integrate it with a medical care’s internal skills. Additionally, they defined technological capabilities as the institution’s ability to create new goods, services, or working methods. Therefore, institutions can easily incorporate the mandatory report systems to avoid medication errors with technological capabilities as nurses are not immune to making mistakes.

Financial Resources

The financial resources at the disposal of healthcare organizations could prove worthwhile in implementing the improvement plan. Medical institutions receive funding from the national government and other avenues requiring over-the-counter payments.

Hospitals are also involved in profit-making initiatives that act as a source of finance. The cost of installation of the technique requires the availability of capital to aid the process. Since the system requires human monitoring, the services must be paid for to ensure the improvement plan works at all times. The personnel putting the mandatory reporting mechanism in place would also need to be paid for their services. Additionally, maintenance and repair costs would also be necessary for the enhancement safety plan to function, to meet the needs of the clinical setting of minimizing medical errors among clinicians to improve patient safety and satisfaction.

Conclusion

Medical errors are a significant cause of morbidity, hospitalization lengthening, mortality, and elevated healthcare expenses. The root-cause analysis of the elements that contribute to medication mistakes at a significant clinic revealed pertinent data about the primary causes and possible alternatives to implement. The review explored how inadequate patient data management contributes to drug mistakes in a hospital setting. The report examined evidence-based options for resolving the issue, offering critical insight into the modifications required to address the recent spike in pharmaceutical errors reported. The solution, which is based on two techniques, will aid in the reduction of adverse drug events by acknowledging both the human and environmental sources of the problem.

References

Amit-Aharon, A., Melnikov, S., & Warshawski, S. (2020). The effect of evidence-based practice perception, information literacy self-efficacy, and academic motivation on nursing students’ future implementation of evidence-based practice. Journal of Professional Nursing, 36(6), 497-502. Web.

Charles, R., Hood, B., DeRosier, J. M., Gosbee, J. W., Bagian, J. P., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2017). Root cause analysis and actions for the prevention of medical errors: Quality improvement and resident education. Orthopedics, 40(4), e628-e635. Web.

Evans, J. M., Brown, A., & Baker, G. R. (2017). Organizational knowledge and capabilities in healthcare: Deconstructing and integrating diverse perspectives. SAGE Open Medicine, 5, 1-10. Web.

Graber, M. L., Byrne, C., & Johnston, D. (2017). The impact of electronic health records on diagnosis. Diagnosis, 4(4), 211-223. Web.

Marmor, R. A., Clay, B., Millen, M., Savides, T. J., & Longhurst, C. A. (2018). The impact of physician EHR usage on patient satisfaction. Applied Clinical Informatics, 9(01), 011-014. Web.

Pelaccia, T., Messman, A. M., & Kline, J. A. (2020). Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. Patient Education and Counseling, 103(8), 1650-1656. Web.

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