NURS FPX 4020 Assessment 2: Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis

 
Root cause analysis (RCA) is an issue and problem analysis methodical process, which is used in identifying potential causes related to adverse events, sentinel, near misses, and conflict in the workplace (Kellogg et al., 2016). The purpose of this paper is to apply RCT to the case study to apply EBP strategies to address sentinel events, develop a safety improvement plan, and identify organizational resources that can aid in improving the safety improvement plans. A case study related to medication error in health care, which led to sentinel events of allergic reaction and blame culture was selected for analysis. The allergic reaction included difficulty in breathing and severe dizziness. In the selected scenario or case study, the team was made up of a staff nurse, a risk manager, a pharmacy technician, and a medication dispenser. The risk manager was the mediator or the leader of the interdisciplinary team, who has the role of facilitating and directing the RCA process to solve the conflict and find the causes (Kellogg et al., 2016).

Analysis of the Root Cause
NURS FPX 4020 Assessment 2: Root-Cause Analysis and Safety Improvement PlanIn the case study, a patient was admitted to the hospital to get treatment for acute diverticulitis. A prescription order of 50 mg Tramadol hydrochloride for every 6-hour PRN pain was sent to the pharmacist. However, it was not administered for the past 8 hours and the patient was asking for the pain medication. The nurse could not administer the medication as the bar-code scanner was not working. However, the nurse used an internal entry number in the computer to assess whether the correct medication was sent. The entry showed that the medication was 325mg, but the medication package said 50mg. The staff nurse followed the hospital’s guidelines to scan the medication barcode, check the medication in the system, and contacted the pharmacist to report the error.

The pharmacist informed the nurse that there is one digit difference between Ultracet (325mg) and Ultram (50mg) and asked the nurse to administer the medicine and alleged that she might have typed the number wrong. As a result, the nurse administered the medication as the patient was in pain and this led to difficulty in breathing and dizziness. Later, the nurse checked the patient’s record and found that he was allergic to acetaminophen. After that, treatment was provided to the patient and the nurse logged a medication incident report. However, the pharmacy technician and nurse manager failed to take the medication error responsibility and this resulted in a blame culture. As the nurse detected both the error and the allergic reaction, she was at the center of RCA.

As the RCA team helps in analyzing the issue and finding the root cause of the problem, it included a risk manager, a full-time RN in the unit, and a full-time pharmacy technician from the pharmacy. The Risk manager helps in identifying different threats to patient safety. The full-time RN will provide expertise on MAP and also explains the process behind barcode medication administration. The pharmacy technician helps in explaining the process behind filling medication dispensing machines (Kellogg et al., 2016).