The Root Cause Analysis of Wrong Medication Administration & The Ways of Preventing Medication Error in Future

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The Root Cause Analysis of Wrong Medication Administration &

The Ways of Preventing Medication Error in Future

Wrong Medication administration or Medication error is one of the major six clinical errors identified by Joint Commission (Singh et al., 2022). Root-cause analysis of the Medication error is a widely used means to understand the factors that contribute to the wrong medication administration and helps the stakeholders move beyond blaming an individual for the medical error but to identify all the factors in the system that have contributed to the errors (Dolansky et al., 2013). This paper will first evaluate the Root cause analysis of Wrong Medication administration or medication error that would identify all the key stakeholders involved or being responsible for the medication errors. It will then find out the 5Whys of the root-cause followed by how medication errors can be prevented in the future.

Root Cause Analysis of Wrong Medication Administration

The first step in the root cause analysis of the medication error is to find out the factors that can be responsible for the medication error. Some associated factors can be environmental, personal, communication among unit members, cultural background and education (Dolansky et al., 2013). The stakeholders involved in these settings are the doctors, nurses, pharmacists, subordinate staff, patient themselves, their kin, the settings in which medication are kept and the tools used for communicating about medication administration. 

5 Whys of the Wrong Medication

The next step is to find the 5Whys of the medication error. For instance, for an incidence of wrong medication administration, the 5 whys can be:

Why? Were the patients with similar names placed in the same room?

Why? Was patient wristband not checked?

Why? Was the print on wristband not visible?

Why? Healthcare system purchased an unreliable printing service?

Why? A Nursing culture of just getting the job done exists?

With separate teams designated to find 5 Whys (Card, 2016), the teams can find out the reasons of the cause of wrong medication administration to the patient and can find a solution to get the things rightly placed and in a right order. 

Preventing Medication Errors in the Future

To prevent such a medication error in future, the primary tool used can be Right communication within the multidisciplinary team involving all the key stakeholders (Singh et al., 2022). In the above case, the environment for the patient, the nurse administering the dose, the healthcare system with wrong patient wristband, the pharmacists and the doctors’ communication could have had the loop holes that might have led to such a medical error. Therefore, it is necessary to keep into account all the factors and all the stakeholders to enable them to perform their duties to the best of their abilities to deliver safe healthcare to the patient. 

Conclusion

Concluding, the role of fair communication in an environment conducive for the healthcare of the patient to be delivered by the healthcare system considering their cultural background by the right personnel involved in the right form is a must for the best healthcare outcome. 

References

Card, A.J. (2016) The problem with '5 whys'. BMJ Quality & Safety. Available at 

https://www.researchgate.net/publication/307599981_The_problem_with_'5_whys'

Dolansky, M. A., Druschel, K., Helba, M. and Courtney, K. (2013) Nursing Student Medication 

Errors: A Case Study Using Root Cause Analysis. Volume 29, Issue 2, Pages 102-108.

https://doi.org/10.1016/j.profnurs.2012.12.010 .  Available at 

https://www.sciencedirect.com/science/article/abs/pii/S8755722312002980

Singh, G., Patel, R.H. and Boster, J. (2022) Root Cause Analysis and Medical Error Prevention.

StatPearls. Available at https://www.ncbi.nlm.nih.gov/books/NBK570638/#!po=2.94118