2. Root-Cause Analysis and Safety Improvement
Plan
• Improper medication administration can lead to:
• Preventable Complications
• Death
• It usually occurs due to human errors (Keers et al., 2013)
• It leads to detrimental consequences such as:
• Compromising patients’ health
• Derailing the purpose of medicine administration
• The root cause analysis explores issues that led to wrong dosage
administration
3. Analysis of the Root Cause
• Two patients presented with complications relating to the dosage
• They were admitted identify the issue and address it
• Erroneous drug dosage resulted in adverse reactions that affected their
recovery
• Immediate attention was required to prevent the incident from reoccurring.
• The root cause of the medication error in this institution was:
• Lack of communication
• Human Error
4. Application of Evidence-Based Strategy
• The administration of wrong dosages was due to:
• lack of proper communication
• human error due to ineligible handwriting
• A study found that 75% of pharmacists were able to read ineligible
handwritings.
• Pharmacists had the biggest issue when reading ineligible writing
• Poor Communication was also attributed to administration of wrong
dosages.
5. Application of Evidence-Based…, Continued
• Proper communication ensures:
• Cohesive working relations among healthcare providers
• Provision of the best patient care
• A study found that poor communication to result in:
• More medical errors
• Harm to patients
• Disruption of patient Recovery
• A healthy working environment fosters a culture of open communication
• Sharing information is especially important for new employees
6. Improvement Plan with Evidence-Based and
Best-Practice Strategies
• A closed-loop Electronic Medication Management Systems (EMMS) can be
implemented remedy human errors
• It supports all phases of medication management including:
• Prescription
• Dispensing
• Administration
• It eliminates the need to write prescriptions on paper pads
7. Improvement Plan with Evidence-Based…,
Continued
• Pharmacists will key in prescriptions and access them their computers in
real-time
• It limits human errors caused by ineligible handwriting
• It facilitates seamless dispensing and administration of medication
• It checks correctness of information while physicians are prescribing
drugs
• It will be implemented in four months with the following key stages:
• Vetting and selecting a vendor
• Preparing and training employees for the change
• System integration
• Evaluation of progress and making necessary adjustments
8. Existing Organizational Resources
• Implementation of the EMMS system will be led by the IT department
• It will vet and choose the best vendor to supply the system
• It will prepare the digital resources available in the care facility
• It will manage the integration of the EMMS
• The HR department will help:
• Employees transition to the new system
• Health staff understand the importance of the change
9. Conclusion
• Medication errors cause:
• preventable complications
• or even death.
• The errors may be due to:
• Poor handwriting
• Lack of communication
• Integrating an EMMS can help improve safety
10. References
Austin, J. A., Smith, I. R., & Tariq, A. (2018). The impact of closed-loop electronic
medication management on time to first dose: A comparative study between paper
and digital hospital environments. International Journal of Pharmacy Practice,
26(6), 526–533. https://doi.org/10.1111/ijpp.12432
Brits, H., Botha, A., Niksch, L., Terblanché, R., Venter, K., &Joubert, G. (2017). Illegible
handwriting and other prescription errors on prescriptions at National District
Hospital, Bloemfontein. South African Family Practice, 59(1), 52–55.
https://doi.org/10.1080/20786190.2016.1254932
Frydenberg, K., &Brekke, M. (2012). Poor communication on patients’ medication
across health care levels leads to potentially harmful medication errors.
Scandinavian Journal of Primary Health Care, 30(4), 234–240.
https://doi.org/10.3109/02813432.2012.712021
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. Drug Safety, 36(11), 1045–1067.
https://doi.org/10.1007/s40264-013-0090-2
Editor's Notes
Medication administration safety concerns have become a pervasive issue in care settings resulting in preventable complications or death
Medication administration issues are often unintentional and usually occur due to human errors (Keers et al., 2013)
They can result in detrimental consequences for both patients and healthcare organizations, derailing the intended purpose of administering medication
Administering the wrong dosage is a medication administration safety issue that has raised a lot of concern
The root cause analysis will explore the issue that led to wrong dosage administration in the acute care setting in a rural area
