RCA is a tool designed to help identify not only what and how an event occurred, but also why it happened. Below is the article we will be doing the root cause analysis

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Running head: MEDICATION ERRORS IN THE HEATHCARE SETTING 1

MEDICATION ERRORS 9

Medication Errors in the Healthcare Setting

Student Name

X Community College

NURS 2448 Restorative 2

Melissa Wolff

Due Date

Abstract

This root cause analysis paper focuses on medications errors which occur in the healthcare setting from lack of communication and distractions. These factors are present in a statement where two nurses fail to use communication and are distracted by environmental influences, which overall lead to a medication error which could have caused a sentinel event to occur. Through data collection and analyzing the sequence of events which lead to the error, this paper will examine ways in which evidenced based practice can be implemented to prevent medication errors like this from occurring in the future.

Keywords: medication errors, communication, distractions

Medication errors cause at least one death every day, and injure approximately 1.3 million people annually in the United States (“Medication Error Report,” n.d.). A medication error can occur at any time during the medication administration process, from when the doctor writes the order to when the patient takes the medication. It is important for those who administer medications to be competent about the medication, while also following the seven rights of medication administration. There are many factors which can lead to medication errors, specifically lack of communication and distractions. Through utilizing evidence based practice, one will be able to learn ways to prevent medication errors from occurring.

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One day while at work I witnessed a medication error occur between two nurses. Sally, one of the residents, suffers from major anxiety which impairs her ability to function normally. As part of Sally’s morning medications, she receives an Ativan along with her other medications. On this particular day, the primary nurse was in charge of passing medications and was also training, which lengthened her medication pass. It takes longer to explain how things are done when training in a new employee. When the primary nurse went to give Sally her pills, Sally refused her medications. Normal protocol when a resident on the memory care unit refuses their medications is to have another staff member attempt giving the medication before documenting a refusal. After Sally refused the medication, the primary nurse called the nurse supervisor to attempt giving Sally her pills. In preventing Sally feeling overwhelmed when taking her pills, the nurse supervisor took just the Ativan out of the medication cup, and left the remaining pills on the medication cart with the primary nurse. The primary nurse placed Sally’s medication to the side on top of the cart, so she was able to get other patients pills started in attempt to stay on track. As the nurse supervisors attempt also failed at giving Sally her Ativan, the nurse supervisor then returned the Ativan to the medication cart to put it back with her other pills. The nurse supervisor dumped the Ativan in another patient’s cup not realizing they were not Sally’s pills, and left in a hurry returning to her work. The primary nurse did not realize this at the time, because one of the Certified Nursing Assistants (CNAs) was talking to them about another issue. After her conversation, the primary nurse went to deliver other patients pills. When they returned, they were again going to attempt to give the Ativan to Sally. When the primary nurse went to take the Ativan out of Sally’s medication cup, the primary nurse realized it was not in her cup and the Ativan must have been dumped into the other patient’s cup, which she just gave. When a medication error occurs, a rapid letter must be sent to the patient doctor explaining what happened, along with starting a 24 hour vital sheet, and corrective action taken for the staff who were involved in the error. All of this could have been prevented with better communication and lack of distraction.

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After reviewing the problem statement, we will now collect data based on the situation to determine the contributing factors which lead to the event. One of the reasons the medication error occurred was due to the primary nurse training in a new employee and already being behind in their medication pass. On top of training, the primary nurse was also on a memory care unit, which can often times be nosey and one can easily become distracted. According to Choo, Hutchinson & Bucknall (2010), environmental conditions such as poor lighting, interruptions and poor communication within teams lead to medication errors. Distractions play a huge role in a person’s work environment and involve events which hinder the medication administration process through sidetracking the nurse’s attention. With the nurse having to talk to the CNA, this was another factor which led to the event. A study by Mayo and Duncan found nurses who were distracted by other patients, co-workers or events happening on the unit reported they made medication errors (Choo et al., 2010). When the house supervisor came to return the Ativan, she was in a hurry to get back to her work, which is why she assumed she had the correct medication cup and proceeded to dump the Ativan in it. According to Judd (2013), failure in communication is the main cause of sentinel events, medication errors, and preventable costs which result in inadequate treatment for patients. Keeping in mind these outcomes from poor communication, it is important to analyze the events which lead to medication errors and determine ways in which they can be prevented.

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After collecting data, we will look at ways in which the communication between the nurses could have been improved and ultimately prevented the medication error for happening. The nurse supervisor could have waited until the primary nurse was done with their conversation with the CNA. This way, the nurse supervisor could ask which medication cup was Sally’s, which would ensure the Ativan was being placed in the correct medication cup. In this case, the nurse supervisor assumed she had the right medication cup and ended up putting the Ativan in another patient’s cup. The nurse supervisor was also in a hurry to get back to her work, which also lead to the medication error occurring. Communication could have been improved through having the primary nurse stopping the conversation with the CNA to make sure the Ativan was put back in Sally’s cup. If active listening was implemented in this situation, the medication error could have been prevented. Nonverbal communication could have been implemented by the nurse supervisor labeling a separate cup with the residents initials and room number (since rooms numbers do not change in this facility), and then the primary nurse could have put the Ativan in the correct cup once they were done discussing a situation with the CNA. In this case, too many people were in charge of the medications which lead to a breech in communication and ultimately resulting in the medication error. Possessing good interpersonal communication skills leads to professional relationships which provide growth in the nursing profession and allow employees to work well together.

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After analyzing the sequence of events which lead to the error, we will look at ways to implement evidenced based practice so future errors can be prevented. In a study done by Flynn, Evanish, Fernald, Hutchinson, and Lefaiver (2016), they implemented the Nurses Uninterrupted Passing Medications Safely (NUPASS) guidelines for nurses to follow while passing medications to decrease the amount of medication errors from occurring. For nurses to not be interrupted during their medication pass, they should don a yellow safety vest before leaving the medication room (Flynn et al., 2016). Not only did they design a vest to wear to alert others the nurse was passing medications, and should not be interrupted, but they also designated a room for those who are passing medications to have a “quiet zone”. Designating a proper administration room for medications would also be beneficial to reduce the interruptions which occurred in the problem statement. This would significantly decrease distractions by allowing the nurse to work in a quite environment and allow them to concentrate and have their attention on dispensing their medications. According to Flynn et al. (2016), implementing a No Interruption Zone (NIZ), would be beneficial by outlining an area on the floor. When a nurse is within the NIZ, no one is to interrupt the nurse. By doing this, one study showed avoidable interruptions decreases from 18 to 3 (83%) on one unit and from 19 to 9 (53%) on another unit after applying the NUPASS guidelines (Flynn et al., 2016). This study greatly supported the use of evidenced based practice to eliminate disruptions pertaining to medication errors.

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After reviewing evidenced based practice for disruptions, we will now use evidenced based practice and look at ways it can improve communication among coworkers. Current research indicates that ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm (Dingley, Daugherty, Derieg, & Persing, 2008). Medication errors are often caused by lack of appropriate communication between staff members which in turn plays a contributing role in adverse events. In a study done by Dingley et al. (2008), they found “using daily briefings was useful in assessing change in clinical workload, and identifying relevant issues of the day, and provided a means to prioritize.” This study also developed a toolkit which can be purchased on the internet and be implemented in different healthcare settings. This toolkit provides information on ways to improve teamwork and communication in the healthcare setting. According to Dingley et al. (2008), they also encourage management and leaders to demonstrate teamwork and communication to show how important these factors are in contributing to patient safety and staff satisfaction. Overall, teamwork and communication are vital factors which contribute to the patient’s safety and wellbeing.

Nurses deal with a great amount of responsibly and challenges every day at work, along with having to deal with multiple demands. This results in nurses being in situations which put them at increased risk for making a medication error. “Medication errors are never the result of a single, isolated human error but comprise a chain of events leading to an error” (Choo et al., 2010). It is important safe practices are put in place to prevent these errors from occurring in the future. By initiating “quiet zones”, NIZ, and wearing vests to alter others you are passing medications, will ultimately result in fewer interruptions during a medication pass. Having staff properly educated on teamwork and collaboration will also positively impact the work environment and prevent errors from occurring. Overall, patient safety is the number one priority in any healthcare setting. Through implementing these practices this will greatly reduce the likely hood of a sentinel event from occurring in the future.

Casual Factor Chart

Sally is due for her morning medications

Steps leading up to event

Root Cause

Primary Nurse- Give Sally her medications

Sally refuses her medications

Sally takes her medications

Primary Nurse continues with med pass (sets up other patient’s pills)

Primary Nurse contacts House Supervisor to attempt

Successful

House Supervisor attempts to give medication

Not successful return to med cart

Take out Ativan

Sally’s pills are pushed to the side on top of med cart

Other patient’s pills are set up on top of med cart

Ativan was put in wrong resident medication cup

Attempt to give just the Ativan

Return Ativan to medication cup

Sally’s pills are set up on med cart

Not successful

If successful, will come back later to give rest of pills

References

Choo, J., Hutchinson, A., & Bucknall, T. (2010). Nurses' role in medication safety. Journal of Nursing Management, 18(7), 853-861. doi:10.1111/j.1365-2834.2010.01164.x

Dingley, C., Daugherty, K., Derieg, M., & Persing, R. (2008). Improving Patient Safety Through Provider Communication Strategy Enhancements. Retrieved November 9, 2016, from https://www.ncbi.nlm.nih.gov/books/NBK43663/?report=reader.

Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration. Critical Care Nurse, 36(4), 19-35. doi:10.4037/ccn2016498

Judd, M. (2013). Broken Communication in Nursing Can Kill: Teaching Communication Is Vital. Creative Nursing, 19(2), 101-104. doi:10.1891/1078-4535.19.2.10

Medication Error Reports. (n.d.). Retrieved October 30, 2016, from http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm

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