Root-Cause Analysis and Safety Improvement Plan

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Root-Cause Analysis and Safety Improvement Plan

Introduction

Medication errors in healthcare will be the topic of the root-cause analysis. Medication mistakes are among the most frequent health risks compromising patient safety, pushing up mortalities, lengthening hospital stays, and driving up treatment costs (Ragau et al., 2018). Lack of pharmacological understanding, inability to follow the management chain of command, and inability to closely monitor the patients are a few factors contributing to pharmaceutical errors. Tragically, while operating at a long-term community hospital, I was made fully aware of the reality that medical transcribing errors can prove fatal. The analysis case is a medication delivery mistake that occurred when two nurses assigned to a patient failed to administer the Prednisone drug. They erroneously stopped after 20 days when it was intended to continue indefinitely. The incident happened when a 36-year-old man went to the facility with generalized body aches and a high fever. The incident caused patients' death, and even though I was not a part of the error, I collaborated with the two nurses involved. This essay will apply the root cause analysis methodology to assess the factors that impact medication errors and how these errors could be reduced to enhance patient safety. It analyzes the issue's core causes to enable organizations to understand better the risk factors that endanger patient safety and develop and implement a sound solution.

Analysis of the Root Cause

Root cause evaluation is a systematic procedure for determining issues or incidents' underlying causes and aggravating factors. The culture of health care has changed, moving the focus from specific employees to the system regarding responsibility for medical errors. I concur with the author's claim that Root Cause Analysis is the most excellent technique for figuring out how and why an incident occurred and is essential to coming up with the proper preventative measures. Medical errors commonly have several causes, which include but are...