Root-Cause Analysis and Safety Improvement Plan
For many years, the policy regarding sentinel events set by the Joint Commission continues to state that all healthcare institutions must have policies that are able to respond to and investigate sentinel events when they occur. One of the primary challenges of a NURS fpx4020 Assessment 2 healthcare institution is medication errors, which can be classified as sentinel events. Hence, the root-cause analysis methodological approach was selected to identify the most prevalent types of drug medication errors committed during the administration of medications to geriatrics in order to formulate appropriate corrective strategies. The purpose of this article is to describe and analyze medication errors and provide evidence-based strategies to overcome the problem. The article also provides the safety improvement plan that can support and resources available for the setting of a healthcare institution for incidents of medication error.
Analysis of the Root Cause
Toivo et al. (2019) state that the health problems within the population are constantly increasing and becoming more complex with the aging of the population, as this often requires more and more advanced medicines. Concerning the patients’ poor remembrance capabilities combined with the grueling work shifts allotted to nurses, it is easy to understand how both sides become forgetful. In the same way, omission or faulty communication causes mistakes in the system (Obua, 2019). In the broad sense, medication errors are all-inclusive. These are the patient’s safety issues posed, alongside all other actions conducted by all participants, from the manufacturer to the patient, in relation to the drug. In addition, Toivo et al. (2019) also said that inappropriately skipping schedules as well as using Within medications are the most pronounced omissions committed by older patients. The risk of health complications resulting from the negligent setting of such standards is fundamentally grave since the mentally wounded, as well as people with disability, have increasing expectations.
NURS fpx4020 Assessment 2 Root Cause Analysis
Because of the negative impact of medication errors on clients aged over 65, Toivo et al. (2019) performed a root-cause analysis that sought to understand the major causes of inappropriate medication use and strange adverse drug-drug interactions. The study was held for a period of 12 months in 5 home care units, a private community pharmacy, and a public healthcare center in Lohja, Finland. A total of 129 clients over 65 years of age with at least one prescription and on regular home care were recruited for the study, out of which 97 successfully completed it. Various trained employees, including practical nurses, coordinating pharmacists as well as the patient’s physicians, worked together to achieve the aim of the study. It was hypothesized that the coordination care intervention would lower medication errors and associated risks substantially over 1 year.
Application of the Evidence-Based Strategies
Because most medical mistakes stem from communication failures, care coordination has proven to be an effective strategy for improving patient safety. It refers to the improvement of communication and relations between different healthcare providers as well as patients (Toivo et al., 2019). As a type of coordination, nurses are able to make home visits in order to monitor the patient’s progress and remind them of critical aspects related to the medication. However, with modern open lines of communication, safety can be enhanced by seeking consultation.
In order for home care personnel, patients, or even nurses to make common errors such as taking doses, technological devices like alarm clocks can be used. NURS fpx4020 Assessment 2 health institutions, nurses can be protected against disruption and interruptions in order to maintain concentration during the administration of medication.
Improvement Plan with Evidence-Based and Best Practice Strategies
The strategy employs automated reminders and communication through telehealth apps. Since most people across the globe are familiar with the internet and technology, platforms where patients can be provided with full instructions from their physicians should be created. Unreadable labels on prescriptions will also be dealt with, as the risks associated will no longer exist (Pérez-Jover et al., 2018). These platforms should remain open to facilitate patient-clinician interactions. Note that, NURS fpx4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan, the case of a single forum for practitioners, other means of collaboration overburdening a single individual can also be used. Regular and frequent home visits can augment social media interaction and enhance the monitoring practices of the patients.
NURS fpx4020 Assessment 2 Existing Organizational Resources
Organizational resources need to be looked at to see if the improvement plan can be implemented successfully. Nurses and patients alike need to be trained on the existing telehealth application technology. The need to contact a practitioner will now be solved, as the efforts of clinicians will be united into one system (Toivo et al., 2019).
Conclusion
In conclusion of NURS fpx4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan communication is the basis for achieving positive health results. Many medication errors are avoided, and relevant knowledge is acquired through coordination, consultation, and interaction. Most verbal instructions provided are likely to be forgotten, but technology, together with regular prompts from nurses, can tackle these challenges. In addition to the improvement of safety, this type of care coordination on the defined population is expected to yield more favorable outcomes, such as improvement in mental state and health-related quality of life.
References
Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What causes medication administration errors in a mental health hospital? A qualitative study with the nursing staff. PloS one, 13(10), e0206233. https://doi.org/10.1371/journal.pone.0206233
Obua, U. G. (2019). Strategies for Reducing Medication Errors in an Outpatient Internal Medicine Clinic. https://scholarworks.waldenu.edu/cgi/viewcontent.cgi? article=7917&context=dissertatios
Pérez-Jover, V., Mira, J. J., Carratala-Munuera, C., Gil-Guillen, V. F., Basora, J., López-Pineda, A., & Orozco-Beltrán, D. (2018). Inappropriate use of medication by elderly, polymedicated, or multipathological patients with chronic diseases. International journal of environmental research and public health, 15(2), 310. https://doi.org/10.3390/ijerph15020310
Toivo, T., Airaksinen, M., Dimitrov, M., Savela, E., Pelkonen, K., Kiuru, V., … & Puustinen, J. (2019). Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial. BMC geriatrics, 19(1), 1-13. file:///C:/Users/hp/Downloads/s12877-019-1353-2.pdf