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Root-Cause Analysis and Safety Improvement Plan (Essay Sample)

the task entails writing a root cause analysis of a selected sentinel event. after describing the sentinel event, the task discussed how evidence-based strategies can be used to address it. a safety improvement plan to address the sentinel event was also developed. lastly, the task outlined the organizational resources needed to make the plan work. source..
Root-Cause Analysis and Safety Improvement Plan Your Name School of Nursing and Health Sciences NURS4020: Improving Quality of Care and Patient Safety Instructor Name Month, Year Root-Cause Analysis and Safety Improvement Plan Root cause analysis (RCA) involves identifying causal factors causing variations in performance. In healthcare, RCA is critical in preventing medical errors and alleviating the consequences caused by such mistakes. The Joint Commission mandates all healthcare institutions to have a comprehensive process for systematically analyzing sentinel events. RCA is often the tool of choice for healthcare practitioners in error analysis. The RCA process helps optimize patient care and implement measures for mitigating adverse events detrimental to patient safety (Singh, Patel, & Boster, 2022). RCA will be used for the selected real-life event involving drug mislabeling. The context of the event was a nursing home, a sensitive healthcare setting where errors easily cause fatalities and critical injuries to patients. The event involved a nurse administering 40 units of Levemir instead of 40mg of Lovenox. The consequence was a drastic drop in the patient's blood sugar level, and the patient had to be sent to the emergency room. Glucagon was administered to correct the error, and even though the patient survived, the mistake could have been fatal. The error emanated from poor practices in labeling drugs and other medicines. Analysis of the Root Cause The sentinel event for which RCA is conducted is administering the wrong medication to a patient. A nurse administered 40 units of Levemir while she was supposed to administer 40mg of Lovenox. The result of the mistake was that the patient's blood sugar level dropped drastically. The patient had to be rushed to the emergency room and given glucagon. The nurse noticed various symptoms of low blood sugar levels, which was not the expected reaction. Levemir treats high blood sugar, meaning a drop in blood sugar level would be expected after the injection. However, the symptoms of low blood sugar were severe because the patient was not being treated for high blood sugar. The error critically affected the patient by endangering their life. Due to the severity of the symptoms, the patient’s life was saved by administering glucagon in the emergency room. Incidents of medication errors are common in hospitals and, in some instances, cause serious legal consequences. For example, a recent event involved a nurse who erroneously administered vecuronium to a patient who was supposed to get Versed (Kelman, 2022). The event made news headlines, and the nurse was charged with reckless homicide and felony abuse. In this case, the impaired patient died, which explains why legal action had to be taken. Further details of the event include that the nurse failed to take full responsibility and expressed that the fault was not hers alone. Her license was revoked, and she lost her nursing career. Such events often occur due to careless behavior among nurses, for instance, not checking if the medication is correct. Failure to correctly label medicines may also contribute, especially where multiple medications are stored in the same area. Lack of communication among practitioners may also result in errors, especially when a nurse fails to clarify or confirm the drug to be administered. Other issues in healthcare may also contribute to such errors. For example, burnout and fatigue may cause nurses to lose concentration, leading to serious errors. Application of Evidence-Based Strategies Medical errors have been extensively covered in academics and practice due to the potential consequences. Available literature offers viable solutions to medical errors and recommends best practices. Evidence-based practices have also featured extensively in the literature, with the most common recommendation being effective reporting systems. In essence, error reporting systems are designed to reduce the likelihood of injury to future patients (Al Mutair et al., 2021). Empirical evidence suggests that underreporting medical errors account for a significant percentage of the costs per patient. Additionally, underreporting is associated with high mortality rates associated with medical errors. However, reporting systems do not consider preventive mechanisms. Regardless, early warning signals for medical errors can facilitate immediate corrective actions to prevent fatalities. Various best practices, including effective labeling of drugs, can guide preventive approaches. For example, the case scenario provided earlier could have been prevented if the medicines were effectively labeled. Imprints and codes should be distinct and legible to avoid confusion. Package design should also be differentiated to ensure correct use. For instance, different colors for different drugs could be used to ensure nurses are not confused. Another approach could be labeling the medications based on the intended treatment. For example, syringes and drug containers could be labeled as 'diabetes treatment' or 'high blood pressure' to help nurses find the correct drugs. Improvement Plan with Evidence-Based and Best-Practice Strategies A feasible improvement plan for the case scenario can be designed based on evidence-based practices and best practice strategies. The proposed idea involves using large colorful stickers on medications that generalize categories to avoid a similar incidence. For instance, there would be a DIABETES sticker on the Levemir pen and a BLOOD THINNER sticker on the Lovenox syringe/injection. Current literature provides evidence to support this plan by indicating that illegible labelling and writing imprecise dosages cause similar errors (Taroq et al., 2023). The desired outcomes of the plan include zero errors in prescriptions, nurses being informed of patients' illnesses, and always matching patients with the specified treatments. Regarding the milestones, the plan will be will be implemented immediately, and the nurses will be educated on the new med...
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