Medication Mishap Root Cause Analysis Worksheet

 

Complete the table below to analyze the Week 4 case study. The analysis questions in the table have been adapted from The Joint Commission’s Root Cause Analysis and Action Plan Framework you reviewed in this week’s learning activity.

Assignment Content

https://psnet.ahrq.gov/webmm/case/314/multifactori…

Read the Multifactorial Medication Mishap case study and the commentary that follows.

Complete the root cause analysis worksheet to analyze the case

Write a 525 word-summary in which you:

Explain why a root cause analysis was appropriate for this situation.

Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care. (YOU MAY CHOOSE THE TOOLS YOU LIKE TO USE)

Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.

 

Analysis Questions	Considerations	Root Cause Analysis Findings	Root Cause (Y/N)
What was the intended process flow?	List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event.
Were there any steps in the process that did not occur as intended?	Explain in detail any deviation from the intended processes.
What human factors were relevant to the outcome?	Staff-related human performance factors such as fatigue, distraction, etc.
How did the equipment performance affect the outcome?	Consider all medical equipment and devices.
What controllable environmental factors directly affected this outcome?	Consider things such as overhead paging that cannot be heard or safety or security risks.
What uncontrollable external factors influenced this outcome?	Factors the organization cannot change
Were there any other factors that directly influenced this outcome?	Internal factors
What are the other areas in the organization where this could happen?	List where the potential exists for similar circumstances.
Was the staff properly qualified and currently competent for their responsibilities at the time of the event?	Evaluate processes in place to ensure staff is competent and qualified.	N/A	N/A
How did actual staffing compare with ideal levels?	Include ideal staffing ratios and actual staffing ratios along with unit census.	N/A	N/A
What is the plan for dealing with staffing contingencies?	What the organization does during a staffing crisis	N/A	N/A
Were such contingencies a factor in this event?	If alternative staff used, verify competency and environmental familiarity.	N/A	N/A
Did staff performance during the event meet expectations?	To what extent did staff perform as expected within or outside of the processes?
To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous?	Patient assessments were complete, shared and accessed by members of the treatment team
To what degree was the communication among participants adequate for this situation?	Analysis of factors related to team communication and communication methods
Was this the appropriate physical environment for the processes being carried out for this situation?	Proactively manage the patient care environment.
What systems are in place to identify environmental risks?	Were environmental risk assessments in place?
What emergency and failure-mode responses have been planned and tested?	What safety evaluations and drills have been conducted?
How does the organization’s culture support risk reduction?	Does the overall culture encourage change, suggestions, and warnings from staff regarding risky situations or problematic areas?	N/A	N/A
What are the barriers to communication of potential risk factors?	Describe specific barriers to effective communication among caregivers.
How is the prevention of adverse outcomes communicated as a high priority?	Describe the organization’s adverse outcome procedures.	N/A	N/A
How can orientation and in-service training be revised to reduce the risk of such events in the future?	Describe how orientation and ongoing education needs of the staff are evaluated.
Was available technology used as intended?	Such as: CT scanning equipment, electronic charting, medication delivery system, tele-radiology services
How might technology be introduced or redesigned to reduce risk in the future?	Describe any future plans for implementation or redesign.

Medication Mishap Root Cause Analysis Worksheet

 

**Medication Mishap Root Cause Analysis Worksheet**

 

| Analysis Questions | Considerations | Root Cause Analysis Findings | Root Cause (Y/N) |

|——————-|—————-|——————————-|——————-|

| What was the intended process flow? | List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event. | The intended process flow involved medication administration according to established hospital protocols, including verification of patient identity, medication verification, dosage confirmation, and documentation of administration. | Y |

| Were there any steps in the process that did not occur as intended? | Explain in detail any deviation from the intended processes. | Yes, there was a deviation from the intended process as the wrong medication was administered to the patient due to a labeling error. | Y |

| What human factors were relevant to the outcome? | Staff-related human performance factors such as fatigue, distraction, etc. | Human factors such as distraction, lack of attention to detail, and workload pressure contributed to the outcome. | Y |

| How did the equipment performance affect the outcome? | Consider all medical equipment and devices. | Equipment performance did not directly affect the outcome in this case. | N |

| What controllable environmental factors directly affected this outcome? | Consider things such as overhead paging that cannot be heard or safety or security risks. | Environmental factors such as noise levels and distractions in the medication administration area may have contributed to the error. | Y |

| What uncontrollable external factors influenced this outcome? | Factors the organization cannot change. | Uncontrollable external factors such as sudden emergencies or unforeseen interruptions may have influenced the outcome. | Y |

| Were there any other factors that directly influenced this outcome? | Internal factors. | Lack of effective double-check procedures and inadequate labeling protocols were additional factors influencing the outcome. | Y |

| What are the other areas in the organization where this could happen? | List where the potential exists for similar circumstances. | Similar circumstances could occur in any area where medication administration is performed, including inpatient units, outpatient clinics, and emergency departments. | Y |

| Were staff properly qualified and currently competent for their responsibilities at the time of the event? | Evaluate processes in place to ensure staff is competent and qualified. | N/A | N/A |

| How did actual staffing compare with ideal levels? | Include ideal staffing ratios and actual staffing ratios along with unit census. | N/A | N/A |

| What is the plan for dealing with staffing contingencies? | What the organization does during a staffing crisis. | N/A | N/A |

| Were such contingencies a factor in this event? | If alternative staff used, verify competency and environmental familiarity. | N/A | N/A |

| Did staff performance during the event meet expectations? | To what extent did staff perform as expected within or outside of the processes? | Staff performance did not meet expectations due to the medication error. | Y |

| To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? | Patient assessments were complete, shared and accessed by members of the treatment team. | Information availability was adequate, but accuracy and clarity of medication labeling were compromised. | Y |

| To what degree was the communication among participants adequate for this situation? | Analysis of factors related to team communication and communication methods. | Communication among participants was inadequate in conveying medication administration instructions clearly. | Y |

| Was this the appropriate physical environment for the processes being carried out for this situation? | Proactively manage the patient care environment. | The physical environment may not have been optimal due to noise levels and distractions. | Y |

| What systems are in place to identify environmental risks? | Were environmental risk assessments in place? | Environmental risk assessments and mitigation strategies may need to be revisited and reinforced. | Y |

| What emergency and failure-mode responses have been planned and tested? | What safety evaluations and drills have been conducted? | Emergency response protocols and safety evaluations should be reviewed and reinforced to prevent similar incidents. | Y |

| How does the organization’s culture support risk reduction? | Does the overall culture encourage change, suggestions, and warnings from staff regarding risky situations or problematic areas. | N/A | N/A |

| What are the barriers to communication of potential risk factors? | Describe specific barriers to effective communication among caregivers. | Barriers to communication include noise, distractions, and lack of clarity in instructions. | Y |

| How is the prevention of adverse outcomes communicated as a high priority? | Describe the organization’s adverse outcome procedures. | N/A | N/A |

| How can orientation and in-service training be revised to reduce the risk of such events in the future? | Describe how orientation and ongoing education needs of the staff are evaluated. | Orientation and in-service training should focus on medication safety protocols, labeling standards, and error prevention strategies. | Y |

| Was available technology used as intended? | Such as: CT scanning equipment, electronic charting, medication delivery system, tele-radiology services. | N/A | N/A |

| How might technology be introduced or redesigned to reduce risk in the future? | Describe any future plans for implementation or redesign. | Technology enhancements such as barcode scanning systems for medication administration and electronic prescribing may reduce the risk of medication errors. | Y |