Quality Care & RCA Team Discussions
Quality Care & RCA Team Discussions
NURS 4220 Week 4 Discussion Initial Post Johnston, D.
The composition of the RCA team consists of a staff nurse, pharmacy technician, and the risk manager to bring together the current focus to assist in medication errors that have taken place for the eighth time within the month. Nursing can bring forth the current challenges that could have contributed to the errors, the pharmacy can bring their expertise to their role in the process of medication administration, and lastly, the risk manager assisting in providing support to both areas to review the facts within the errors and assist in the development of using the Pareto chart for problem-solving (Yoder-Wise, 2019).
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Both nursing and pharmacy came to recognize that no one is to blame, instead, a strong commitment to work through the current details that created the errors. Staffing shortages were part of the initial discussion as real challenges for both nursing and pharmacy, but the risk manager wanted to first look at the current events around the medication errors. Nursing started strong with directing blame to the pharmacy, but then took responsibility for not shifting blame as they work to problem-solve together.
All of the possible root causes were pulled from event reports for medication errors that included the reason for the error. There is a list of 12 most common medication errors and of the 12, there were only 7 that resulted from the event reporting. Interestingly enough, staffing was not one of them. The highest of contributing errors 102 was from defective scanning, 60 from look-alike medication labeling, and 60 from pharmacy/tech stress errors. The inability to communicate with the pharmacy resulted in 15 errors. Nursing had a total of 15 errors that were due to unfamiliarity with medication names and five rights.
The nursing staff can provide a review for the 5 rights for safe medication administration and laminate the 5 rights to each of the workstations on wheels to assist with an easy reference tool for medication administration. With the partnership with the pharmacy, providing the brand and generic name for a drug could assist with unfamiliarity with medication names. When it comes to the support needed from Pharmacy, providing a list of those medications that are not scanning and look-alike medications could reveal trends. It provides a starting point to work from for improvements. One of the more concerning root causes was the 60 errors occurring from pharmacy/tech stress errors.
This would require a deeper dive into those errors to determine if it is a trend with employees, certain times of day, or related to staffing, doing more with less resulting in errors. Starting with a philosophy of a “Just Culture” provides direction that education is first and foremost to provide support to the daily practice (Boysen, 2013). A “Just Culture” suggests that one can learn and grow instead of a culture of penalty or punishment.
References
Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. The
Ochsner Journal, 13(3), 400–406.
Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Chicago, IL: Health
Administration Press.
Yoder-Wise, P.S. (2019). Leading and managing in nursing (7th ed.). St. Louis, MO: Mosby
Chapter 18, “Leading Change” (pp. 319-335).
NURS 4220 Week 4 Initial Discussion post Johnston D.docx (16.055 KB)
Paula Miller
RE: Discussion – Week 4
A sentinel event occurred at Downtown Medical as a result of a medication error. A root cause analysis (RCA) team has been assembled consisting of a risk manager, a full-time staff nurse who had the medication error, and a full-time pharmacy technician to determine the medication error (Laureate, 2016b). The risk manager’s role is to motivate the staff nurse and pharmacy tech to contribute their experience and expertise to the processes of discovering the RCA (Spath, 2018). The risk manager re-focused the meeting when staff started to blame each other. She stated the importance of fixing the medication error with an open mind for patient safety. Teamwork is vital to identify all parties’ goals and needs to be involved in producing strategies and outcomes beneficial to the problem under discussion (Yoder-Wise, 2015).
The RCA team began its improvement process by creating a flowchart to establish the steps of administering the medication. Flowcharts allow teams to see the workings of the current process and help the members determine where improvements can be made (Spath, 2018). After the flowcharts were completed, the RCA team members formed a cause and effect diagram to identify why medication errors occurred after CPOE and NDMR processes were implemented. Once the fishbone diagram was complete, and the major causes and subfactors were determined, the RCA team members collected data of medication errors over the last year and constructed a Pareto chart based on the issues identified. Pareto charts help the RCA team to focus on inputs that will have the most significant impact, display data so that it is simple and visually appealing in order of importance, and provides an easy way to compare before and after data to confirm that changes in the process created the desired result (Chartier et al., 2018). The three major causes of medication error were scanner glitches, lack of education regarding generic vs. trade names of medications, and pharmacy technician errors related to stress and burnout. A Pareto chart sorts data from the most frequent to less frequent and places focus on the “vital few” causes an issue that affects eight percent of performance (Spath, 2018).
Identifying these three contributing factors are essential and necessary steps to develop a resolution o eliminate medication errors. Scanners should be repaired or replaced immediately. While nursing staff should always follow the five rights of medication administration. To prevent errors from occurring in the future, the team members need to develop a process improvement plan using a method such as Plan-Do-Study-Act (PDSA) or another model that suits their needs. The team needs to work towards a goal. A team with positive group dynamics tend to trust each other, focus on the issues for improvement, and hold each other accountable to provide quality care and prevent future errors.
References
Chartier, L. B., Cheng, A. H., Stang, A. S., & Vaillancourt, S. (2018). Quality improvement primer part 1: preparing for a quality improvement project in the emergency department. Canadian Journal of Emergency Medicine, 20(1), 104-111.
Laureate Education (Producer). (2016b) RCA dramatization 1 [Video File]. Baltimore, MD: Author.
Spath, P. (2018). Introduction of healthcare quality management (3rd ed.). Chicago, IL: Health Administration Press.
Yoder-Wise, P.S. (2015). Leading and managing in nursing (6th ed.) St. Louis, MO: Mosby
Practice Experience
Sohilla Ahmadi
RE: Pointers for Week 4
Quality care is at the heart of every healthcare worker in any capacity. As patients visits the healthcare facility, they are entitled to receive a proper service which is safe and less life threatening.as well timely. With expectations, nurses and other health workers need to ensure patients safety hospital related infections such CLASBI. Central line- associated bloodstream infection is a major safety concern to every healthcare as it accounts for more death of patients across the globe. Central line-associated bloodstream infection occurs when germs enters the patients’ bloodstream through the central line which later results in a bloodstream infection (Lozano, R. 2020).
In order to improve patient’s safety and improved practice towards minimizing the rate of the infection, there are key measures that needs to implemented in order to achieve the desired outcome towards the infection. The proposed action steps and techniques include; education of the staff about CLASBI rates. In a resource poor environment, the education is of key importance in reducing the rate of CLABSI in hospitals. Basic education concerning the entire phenomena of the infection needs to be made clear to understand the measures needed to reduce the rate of the infection as well as understand the role they play as health care workers in prevention and reduction of the infection.
Another action step in achieving improved practice towards reduction of the rate of infection, involves the enhancement of proper hygiene. Hand hygiene is considered to be the major contributor to the high rates of the infection among the patients majorly in intensive care unit. Maintaining a proper hand hygiene before and after catheter insertion. Also hand hygiene needs to be observed during the dressing of the area used as insertion site of the catheter. Lastly the palpation of the insertion site should be done after the application of the antiseptic or unless otherwise the antiseptic measures and techniques are maintained in order to prevent the occurrence of the infection. Another technique is the application of the antiseptic in the dressing and cleaning of the catheter.
The measures discuss above are faced with many challenges resulting from the cost of the implementation of the measure and also the unwillingness of the health workers to cooperate. For instance, the education of the heath care workers is expensive as well as the purchase of hygienic substances such as antiseptics. Also the implementation of the measures calls for extra personnel in the hospital which is costly.
Reference:
Lozano, R. J. (2020). Psychological Impact of Restraint Practices on Mental Health Technicians in Inpatient Psychiatric Facilities (Doctoral dissertation, Alliant International University).
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Paula Miller
RE: Group B Practice Experience Discussion – Week 4
A fall prevention project is currently underway at a mental health facility. The project’s mission is to strive for excellence in confronting frequent fall incidents among admitted patients and prevent negative physical and psychological consequences such as fractures, pain, infection, and depression. The quality improvement plan consists of a complicated process, including conducting a root cause analysis in post-fall huddles. The proposed action steps for implementing an improved practice by preventing falls on the mental health units may be a challenge, and there may be impediments in implementing a quality improvement plan.
The nursing staff assumes a vital role in fall prevention. Although continuing education is vital for all professionals, it is equally important that nurses provide patients with detailed information about preventative measures related to falls. A primary concern in the mental health unit is inadequate staff engagement in fall prevention. According to one article, it is crucial to educate everyone involved in the patient’s care, even if it is outside the unit, including teaching families about fall prevention strategies. A team effort and communication appear to be needed to impact fall rates (Howard, 2018). Ongoing, continued education of healthcare workers, patients, and family members has been one measure shown by evidence -based practice that decreases falls within a mental health facility. Staff can learn fall prevention strategies through monthly required e-learning education.
Patient rounding is one of the most critical actions health care workers can take to improve patient safety and reduce falls up to 50% (Hicks, 2015). It would be feasible for nursing management to redesign the nursing workload to increase direct patient care contact opportunities. Intentional rounding on every patient, including assessing for falls, identifying environment safety concerns, and attending to patient needs, will increase patient satisfaction and decrease falls (Sun et al., 2020). It has been observed that unlicensed team members do not always perform rounding duties every fifteen minutes as directed—the checklist states where the patient is located and if they are involved in activity or sleeping. Nurses would need a decrease in workloads to monitor patients and direct patient care. Redundant charting is time-consuming. An intervention of modifying and condensing electronic patient records would allow nurses more time on the floors.
Possible difficulties that can compromise these proposed improvements are the compliance of the healthcare providers. Some team members do not like change, getting them to abide by new implementations can be challenging. Some nurses may take shortcuts to save time by not providing detailed information on preventing falls. Staff members may skip a rounding responsibility and initial that the rounding was completed. The project outcome’s success will depend on the team’s ability to address patient falls systematically and largely depend on the cooperation of team members and the department’s organization in implementing change. The project cannot be solved individually and would need a project improvement team that is coordinated by the efforts of different professionals with varying knowledge, skills, and perspectives (Spath, 2018).The resources needed to implement change are managerial support, educational material, incentives, and new computer programming. These interventions are cost-effective and less expensive than the cost involved with patient falls. Less charting for nurses will provide more patient care and fewer falls. Incentives such as pizza parties monthly or quarterly celebrates reduced falls within the facility. It is believed these interventions are the first steps and will positively impact the facility in decreasing patient falls.
References
Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. Medsurg Nursing, 24(1), 51.
Howard, K. (2018). Improving Fall Rates Using Bedside Debriefings and Reflective Emails: One Unit’s Success Story. MEDSURG Nursing, 27(6), 388–391.Retrieved from: https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=9&sid=13ae39e9-09aa-483d-a6ba-415c281e70ae%40sessionmgr4007
Spath, P. (2018). Introduction of healthcare quality management (3rd ed.). Chicago, IL: Health Administration Press.
Sun, C., Fu, C. J., OʼBrien, J., Cato, K. D., Stoerger, L., & Levin, A. (2020). Exploring practices of bedside shift report and hourly rounding. Is there an impact on patient falls? The Journal of Nursing Administration, 50(6), 355–362. https://doi-org.ezp.waldenulibrary.org/10.1097/NNA…