Root Cause Analysis - Delay in Treatment - Term Paper Example

Root Cause Analysis Affiliation with more information about affiliation, research grants, conflict ofinterest and how to contact Root Cause Analysis Introduction: Root cause analysis (RCA) is identifying flaws in the health care system by investigating the adverse effects that may have occurred during the care of a patient. It also intends to improve the functioning of the health care system. The main characteristic features of RCA include: It does not focus on the individual process- mainly intended for the system and process Literature review Conducts extensive research to identify the in depth contributing factors It has the capability to cause a change in the system and procedure. This may be done through redesigning the system or through the introduction of a new procedure or process, so that the incident does not re-occur. Providing a safe environment that is free of blame Involvement of all the members of health team- so that all the members have adequate knowledge on the steps and process Root cause analysis is carried out by identifying a sentinel event. A sentinel event may be a consequence that occur infrequently, may be due to the defect in the process and system and may have an unnecessary result on the patient. Examples of some of the sentinel events include: Procedures that may involve a wrong body part or patient Conducting further surgeries so as to remove instruments and materials that were retained during a surgery Medication errors that leads to the death of a patient Discharging a new born to a wrong family Maternal death associated with labour. How the RCA Works? An interdisciplinary approach is involved in the RCA. The whole staff of the RCA work together to identify the flaws in the health care and contribute effective interventions to prevent its occurrence in the future. A brief summary of the events that occur in the RCA: 1. The incident is described either by using a diagram or flow chart 2. The work flow during the incident is compared with the recommended process 3. The contributing factors are indentified. The following categories are included: Personnel factors that include failures in communication, lack of adequate training or staff shortage Failures of equipments Poor work environment e.g. improper functioning of alarms Lack of adequate protective measures 4. Corrective interventions are identified and processed Medication Error: The major challenge that nurses’ face is medication errors. These errors adversely affect the safety of the patient and may result in health hazards for the patient and family. Administration of medication is one of the critical responsibilities of a nurse as if administered incorrectly may lead to adverse problems to the client. The adverse effects may include increased mortality rate, long stay in hospital and increased hospital bills. Even though others members of the health team administer medications, the medication errors are more common among the nurses. It is because majority of the medications are administered by the nurses and they spend majority of their time in hospitals to administer medications. Studies have proven that medication error increases the stay of patient for about 2 days and increase the cost of care about $ 2000- $2500 for each patient (Cheragi et al. 2013). Therefore, the causes related to each medication error should be identified. Description of the Event: The event may be described by asking a few questions like: What is the problem? For this we know the answer which is medication error When did the incident happen? Specifying the date and time of the incident Where did the incident happen? The place where it happened, maybe a department, ward etc. Did the error have any impact? – specifying details like the following: Did it harm the patient or affect the safety of the patient? Does it have any legal impact on the personnel that administered it? Is there a possibility of legal action against the hospital? Flow Chart: Wrong patient Wrong dose Medication error Wrong type Patient does not receive the needed medication Contributing Factors: There may be number of contributing factors. First we have to identify the cause of the errors. We should detail the steps involved in the administration of medication. The error might have occurred in any of these factors which might be grouped into the following: Error in the prescription of medication Error during the preparation Error while administering to the patient. The whole steps involved are listed down, and then an analysis is carried out to identify the cause. The steps are: Based on the diagnosis, the physician decides the type of medication the patient needs He selects the type of medication Determines the dose needed for the patient Prescribes the medication in written form or enters it Physician describes about the medication to the patient The given prescription is delivered to the pharmacy Pharmacist selects the prescribed medication Pharmacist if needed measures the medication The medication is then delivered to the nurse Nurse carries the medication to the medication area Medication is given to the patient The following errors might have occurred in the above mentioned steps: Error -Physician Physician might have selected the wrong medication Prescribed the wrong medication Prescribed the wrong dose Physician did not explain the details regarding the medication to the client and family Error-Pharmacist Pharmacist delivers the wrong medication Incorrect measurement of the medication Error- Nurse Nurse prepares the wrong medication Administers the wrong dose either over dose or less dose Administers wrong medication to the client. Administers medication to the wrong client Identification of the Route Cause for Delay in Proper Treatment: 1. Patient Receives Wrong Medication When the Nurse Gives the Wrong Medication: Doctor did not explain about the medication to the patient Patient is unaware of the medication Nurse administers the wrong medication Patient does speak about the wrong medication as doctor did not explain Patient receives the wrong drug Here, it can be seen that the root cause for the delay in appropriate treatment to patient is wrong medication. This cause not only hampers the patient from receiving proper medication but also complicates his or her disease as the wrong medicine is given. However this delay in treatment could have been avoided had the doctor explained about the medicine to both the patient and the nurse. 2. Nurse Administers the Wrong Medication Due to Inadequate Checking of the Medication Nurse is interrupted in her task She either takes the wrong medication or is given the wrong medication Nurse does not check the medication Nurse administers the wrong drug to the patient Delay in appropriate treatment can also occur if the nurses themselves fail to check for what medication they provide to the patients. The nurse might not be aware of this mistake, however, end result is that there is a delay in treatment, that is, proper treatment, as the patient receives wrong medication. Furthermore, another factor here is that, when the nurse is interrupted in his or her task, and given other responsibilities, even if they have the correct medication in their hands, they might not be able to provide it to the patient due to other engagements. This also results in delay in treatment, as the patient has to wait till the nurse has finished the new task she was given. 3. The Wrong Medication is Given Either because the Prescription was not Filled Properly or it was for the Wrong Drug. Prescription is not properly filled / Prescription of the wrong medication Nurse is delivered with wrong medication Wrong medication given as a result of wrong prescription also leads to delay in treatment. First of all, it can be seen that significant time passes until the nurse or the doctor comes to know that the wrong medication was given. It maybe found out depending on when the next medication is to be given. Doctors or nurses will find out while giving the next dosage, as they will check the previous dosage details. Then there is a significant gap between replacing the wrong medication as well as providing the proper one. Thus, it becomes clear that this also causes delay in treatment. 4. Pharmacist Fills the Prescription Wrong Pharmacist takes the wrong drugs (mistaken for bottles that look alike) OR Pharmacist reads the prescription wrong (Illegible handwriting) AND Does not check the prescription properly Inaccurate filling of prescription Wrong medication when given out by the pharmacist also causes delay in treatment, as like in above-mentioned cases, the patient is in deed receiving wrong treatment. Thus, wrong drug handed out by the pharmacist also becomes a root cause for delay in the proper treatment. 5. Ineffective Check of Prescription for Wrong Drug Medication names of similar sounds Wrong prescription written by doctor OR Wrong medication selected by the doctor AND Inadequate check of the prescribed prescription Wrong medication prescription At times, the doctor may have lack of attention when he prescribes the medication, this will result in selection of wrong medicine, thus leading to delay in appropriate treatment. Thus, as exemplified above, delay in treatment may occur due to wrong administration of medication, which transpires as a result of miscommunication between the healthcare professionals as well as lack of decision-making or wrong decision making on their part. Furthermore, in certain cases, when there is a lack of staff and the workload of a particular doctor or nurse increases, they are unable to provide prompt treatment to all patients. Thus lack of staff is also a root cause for delay in treatment. Moreover, even when adequate staff is available, sometimes due to the lack of proper priority ascribed to respective cases, there is significant delay in treatment to some patients. Therefore, it becomes clear that inability of doctors or nurses to prioritize appropriately also is a root cause for delay in treatment. Other factors that cause delay in treatment include errors in professionalism such as lack of coordination between the doctor and nurses, lack of appropriate follow up plans, lack of proper scheduling of the patients treatment due to various reasons, wrong reading of test results, lack of awareness of the patients’ short term check up needs etc. Thus all these factors can be identified as the root causes for delay in treatment for different kinds of patients. The causes have been identified. The next step involves preparation of an action plan. IMPACT OF DELAYED TREATMENT ON PATIENT Following the enactment of the Affordable Care Act, it has increased the demands on clinicians and health services, for a new focus on better health outcomes has led to finding ways for preventing the delay in treatment and is major focus of the health care industries. Nancy Foster (1) says that delayed treatment occurs when a patient does not get treatment; it may be either due to medication, lab test, physical therapy treatment or any other treatment- which had been ordered for them in a particular time frame in which it was supposed to be delivered. Delay in treatment was found to be the most common sentinel effect, and cases decreased to 56 in the first six months of 2013 (1). Delay in treatment can affect patient outcomes, especially for cardiac, surgical or other emergency cases. An example illustrated is that, an antibiotic must be administered within 1 hour within incision or prior to the procedure, if there is delay in administration of antibiotic, it may lead to infection in patient and later may lead to serious complications. Other impact that delayed treatment may have is irreversible effects on the patient and death especially in the emergency department. for example, delay in administration of emergency medicines may lead to death of patient. It is also evident that delay in treatment leads to increased hospital stay, more economic burden and may have irreversible effects on patient. Literature Review: Many studies have been conducted in assessing the types of medication error, causes and incidence and preventive measures to reduce the incidence of medication error. In a study conducted by Seyyedeh Roghayeh et al. to enlist the medication errors among nurses in emergency department, concluded that there is high risk of medication error among nurses and it is one of the major problems in nursing emergency department. They found that the most prevalent medication errors included errors in the infusion rate (33.3%) and administration of two doses of medication instead of one (23.8%). Based on their study the most important cause of medication is due to the shortage of nurses (47.6%) and lack of knowledge in pharmacology (30.9%) (Ehsani et al. 2013). Another study conducted by Dilip Kothari et.al. found that medication error is a matter of concern in the critical care units and in the department of anesthesia. They have enlisted many reasons and possible outcomes of medication errors both to the hospital and to the client In a study conducted by Richard N. et al. concluded that factors like inadequate written communication, storage and supply of medications, problems with equipments and high work load of staff are the main reasons for medication error. A study conducted by Mohammed Ali.et.al among the nurses in Iran found that 64.55% of nurses that participated in study committed medication errors. The study found that most reported errors were of wrong dose and infusion rates. The most common causes identified were similar drug names and the use of abbreviations instead of full names. They concluded that the most important cause of medication error was the lack of knowledge among the nurses. A study conducted by Ala Szczepura et.al also proved that the medication error among nurses were high in long term residential care centers. They also suggested the use of barcode administration system that is capable of capturing the medication administration errors and can prevent errors. Based on the above evidence an action plan may be formulated. Action Plan: Educating the health personnel especially nurses. The following key points may be emphasized: Identifying the correct patient either by asking the patient his name or confirm by checking the arm band Adequate knowledge about the drugs and maintaining a drug record or profile There should be adequate communication among the patient and the health personnel which can avoid majority of medication errors The health facility should check the proper packing, labeling and naming of drugs. They should ensure that all drugs are delivered in properly labeled packages. Proper monitoring of the drug delivery device and the personnel should have the adequate knowledge to operate the equipment. The health personnel should be aware of the other factors like poor lighting, interruptions during work and heavier workloads may lead to medication errors Educating the staff especially nurses regarding the medications. Newer medications should be taught with priority. They should be always updated with the different types of medication errors Emphasize should be given to patient education. The patient should be taught about the medication. For instance, for what disease he is receiving the medication, the dose, action, route of administration, possible side effects and about drug interactions. The nurse should follow the rights in medication administration. On the basis of the flow chart analysis the following errors may be corrected. a. If error is due to bottles that look similar: Separate the similar looking medications that get frequently mistaken. b. If error occurred due to incorrect filling of prescription or wrong measurement of drug by pharmacy: Check the prescription list before it leaves the pharmacy c. If the prescription is illegible: Type the prescription d. If the prescription includes drugs with similar sounding names: Check the prescription for brand and generic name. e. To avoid giving wrong dose or wrong medication to the patient: Check the medication before administering to the patient. f. If the doctor did not explain about the medication to the patient: Inform the patient about the purpose of each medication including its brand name. g. To avoid giving to the wrong patient: Check the patient’s identity before administering h. If different doses of medication should be administered at the same place: Administer only one dose at a time. i. If error due to use of incorrect abbreviations: Use correct abbreviations j. If dosage of drug is miscalculated: Check the dosage once again before administering. Evaluation of Plan with Inclusion of New Steps: Physician decides the patient medication Physician decides the type of drug Physician decides the dose of drug Physician writes or enters the prescription Physician explains about the medication to the patient Prescription is delivered to the pharmacy The dose is rechecked Pharmacist identifies the medication Pharmacist measures the drug Pharmacist checks the prescription once again Medication is delivered to the nurse Nurse carries the drug to the medication area Nurse re checks the medication Verifies the identity of patient Medication is administered to the patient Following the evaluation, the medication error can be avoided by using the above mentioned steps. Another example for the identification of root cause analysis-delay in treatment may result in the death of the patient or may result in irreversible outcomes. The delay in treatment may be due to shortage of staff at the time of admission, or absence of the necessary equipments, absence of the necessary medications or due to poor communication among staff. An example is that, the average staff in an emergency department may be overworked, fatigued or distracted and this may lead to delay in treatment in emergency department. some of the other things are that staffing levels are different during the week and the weekends and there are also lack of knowledge and skill among the nurses that may lead to delayed treatment. The root cause analysis tries to identify the exact problems and try to resolve that problem. If the delay was due to the shortage of staff, the management tries to admit more staff in the department. The delay may be due to absence of necessary equipments and medications, and then it should be resolved by implementing it. For the shortage of staff, the departments like ER, critical care units should admit more staff based on the bed strength to avoid delay in treatment. Travel nurses may be admitted that may reduce the staff shortage. The primary importance is bringing up a culture in the unit and hospitals with more focus on patient needs Conclusion: Medication errors are one of the most common sentinel errors that occur in the health care industry. As most of the medications are administered by nurses, it is more common among the nurses and causes a great challenge to the nurse. Various studies have been reviewed that proves the evidence and increased incidence of medication error among nurses especially in critical care departments. It also has been proved that, these errors increases the mortality rate of patients and increases their stay at hospitals. A number of factors have been found, that contributes to the increased number of medication error which include poor communication among the staff and the patient, increased workload of staff, poor monitoring of the medications and lack of knowledge about the medications. Most of medication errors can be prevented by improving the communication between the client and staff, through continuing education to staff and application of newer methods like barcode reading for medication administration. Further research studies may be conducted to improve the right administration of medication among nurses and strategies to improve their knowledge of using the equipments like infusion pump etc for medication administration. Reference List Anderson, P., & Townsend, T. (2010). Medication Errors: Dont let them Happen to You. American Nurse Today. Vol.5 (3): Pp.23-28. Retrieved April 1, 2014, from Cheragi, M. A., Manoocheri, H., Mohammadnejad, E. & Ehsani, S. R. (2013). Types and Causes of Medication Errors from Nurse’s Viewpoint. Iranian Journal of Nursing and Midwifery Research: Medknow Publications. Retrieved April 2, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/ Ehsani,S. R., Cheragih, M. A., Nejati, A., Salari, A., Esmaeilpoor, A. H. & Nejad, E. M. (2013). Medication Errors of Nurses in the Emergency Department. Journal of Medical Ethics and History of Medicine. Pp. 1-7. Retrieved April 1, 2014, from Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M., (2013). Causes of Medication Administration Errors in Hospitals: A Systematic Review of Quantitative and Qualitative Evidence. Springerlink.com. Pp.1045-1067. Retrieved April 1, 2014, from Szczepura, A., Wild, D. & Nelson, S. (2011). Medication Administration Errors for Older People in Long-Term Residential Care. BMC Geriatrics. Vol.11 (82): Pp. 1-10. 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