Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example

 QuestionsConsiderationsRoot Cause Analysis FindingsRoot 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.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example) The intended process flow was: Physician identifying and orders the appropriate medication and dosage through the computerized prescriber order entry (CPOE).The pharmacist receives, verifies, provides, and comment on the prescribed medication. In addition, the pharmacist provided additional labeling to guide the bedside nurse.The bedside nurse reads and administers medication according to the pharmacist’s comments.No. Prescribing, product order communication, and labeling guide easy identification by health professionals and patients to avoid errors (Billstein-Leber et al., 2018(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)
Were there any steps in the process that did not occur as intended?(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Explain in detail any deviation from the intended processes.Yes. Typically, the nurse should observe the physician /pharmacist’s recommendation. For example, the physician prescribed a 5mg dosage, which the pharmacist elaborated to the bedside nurse by labeling and commenting as a 0.25Ml for the available concentration. However, the bedside nurse ignored and instead administered the dosage she is used to.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. Drug administration errors and lack of professional communication contribute to medication errors in clinical settings (Tariq, Vashisht, Sinha, & Scherbak, 2020).
What human factors were relevant to the outcome?Staff-related human performance factors such as fatigue, distraction, etc.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Human ignorance contributed to adverse patient outcomes. For example, the pharmacist included appropriate instructions, the bedside nurse ignored and administered the wrong dosage.Yes. A nurse should review medication orders and ascertain the correctness of the physician’s order and medication administration record (Hassan, 2018).(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)
How did the equipment performance affect the outcome?Consider all medical equipment and devices.The medical equipment listed similar drug entries multiple times, leading to the physician’s identification of several medication choices than there were.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. Medication prescription equipment must be free from errors that would affect medication handling and administration (Godshall & Riehl, 2018).  
What controllable environmental factors directly affected this outcome?Consider things such as overhead paging that cannot be heard or safety or security risks.The controllable risk factors for this incidence include teamwork, communication, and reporting systems.Yes. Managing environmental factors such as appropriate teamwork in a clinical setting and communication between healthcare teams can mitigate against potential mishaps (Tariq et al., 2020).
What uncontrollable external factors influenced this outcome?Factors the organization cannot changeThe patient’s medication response is an uncontrollable risk factor.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. Adverse reaction to medication changes with patient, i.e., a different patient could tolerate the exact dosage.
Were there any other factors that directly influenced this outcome?(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Internal factorsThe other internal factors that influenced the adverse outcome include the lack of a reporting system.Yes. Establishing a reporting system in case of malfunctions can help identify system flaws and guide preventive measures (Tariq et al., 2020).(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)
What are the other areas in the organization where this could happen?List where the potential exists for similar circumstances.In geriatric and pediatric care settings. Children and the elderly present the most adverse medication reactions in clinical settings (Rieder, 2018; Davies & O’mahony, 2015).(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. Clinical personnel should be more sensitive when prescribing medication to children and the elderly by conducting further tests and appropriate monitoring to minimize adverse reactions (Tariq et al., 2020).
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/AN/A
How did actual staffing compare with ideal levels?(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Include ideal staffing ratios and actual staffing ratios along with unit census.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)N/AN/A
What is the plan for dealing with staffing contingencies?What the organization does during a staffing crisisN/AN/A
Were such contingencies a factor in this event?If alternative staff used, verify competency and environmental familiarity.N/AN/A
Did staff performance during the event meet expectations?To what extent did staff perform as expected within or outside of the processes?No. However, the pharmacists performed as expected, providing medication administration comments to the nurse. On the other hand, the bedside nurse failed to check the dose frequency leading to medication error. (Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. It is recommended that nurses consider the adverse reaction of any medication, thus, the need to check and verify the accuracy of the prescribed dosage (Tariq et al., 2020).
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 teamThe patient’s assessments were complete, including negative responses to opioids. However, the assessments were not accurately communicated and accessed by the treatment team.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. The bedside nurse failed to verify administration recommendations from the electronic medication administration record (eMAR) and drug labeling.
To what degree was the communication among participants adequate for this situation?Analysis of factors related to team communication and communication methodsThe communication was not adequate. The physician should have communicated the patient’s naivety to opioids. Equally, the pharmacist would have passed an oral communication to the nurse to stress the significance of the accurate dosage.(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)Yes. The miscommunication between the physician, pharmacist, and bedside nurse contributed to the medication error.
Was this the appropriate physical environment for the processes being carried out for this situation?Proactively manage the patient care environment.The physical environment was appropriate for patient care.No. The physical environment did not contribute to the adverse patient outcome.
What systems are in place to identify environmental risks?Were environmental risk assessments in place?There is no existing environmental risk assessment.Yes. Environmental risk assessments are crucial in mitigating medication errors and causal factors.
What emergency and failure-mode responses have been planned and tested?What safety evaluations and drills have been conducted?The hospital initiated a code blue response to the patient’s critical situation and transferred to the ICU. Moreover, the patient was given naloxone to reverse the effects of opioids.No. The code blue response contributed to the reversal of the patient’s positive status.
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/AN/A
What are the barriers to communication of potential risk factors?Describe specific barriers to effective communication among caregivers.Communication style. In this case, the pharmacist’s communication style, i.e., written comments, was ineffective in communicating crucial dosage instruction to the bedside nurse. On the other hand, there was not clear communication channel for the treatment team.Yes. Poor interaction and communication among treatment team members contribute to team-working errors (Jhugursing, Dimmock, & Mulchandani, 2017).  
How is the prevention of adverse outcomes communicated as a high priority?Describe the organization’s adverse outcome procedures.N/AN/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.Continuous employee performance appraisal would highlight the need for additional knowledge in understanding high-risk medication and the need for effective communication among treatment teams.Yes. Inadequate understanding of medication reactions and poor communication contribute to medication errors (Jhugursing et al., 2017).
Was available technology used as intended?Such as: CT scanning equipment, electronic charting, medication delivery system, tele-radiology servicesNo. While the existing technology was adopted to minimize medication errors, technological glitches and human error affected the outcome. For example, the computerized prescriber order entry malfunctioned, and the nurse failed to check the electronic medication administration record.Yes. Appropriate use of medication systems enhance medication prescription and administration (Jhugursing et al., 2017).
How might technology be introduced or redesigned to reduce risk in the future?Describe any future plans for implementation or redesign.Adopting a reporting system. The systems report even the slightest mishaps and guide prevention measures and recurrence.Yes. Faults in automated medication systems contribute to medication errors (Jhugursing et al., 2017).
(Medication Mishap Root Cause Analysis Worksheet Comprehensive Nursing Essay Example)


Billstein-Leber, M., Carrillo, C. J. D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy75(19), 1493-1517.

Davies, E. A., & O’mahony, M. S. (2015). Adverse drug reactions in special populations–the elderly. British journal of clinical pharmacology80(4), 796-807. 10.1111/bcp.12596

Godshall, M., & Riehl, M. (2018). Preventing medication errors in the information age. Nursing202048(9), 56-58. 10.1097/01.NURSE.0000544230.51598.38

Hassan, I. (2018). Avoiding medication errors through effective communication in healthcare environment. Movement, Health & Exercise7(1), 113-126.

Jhugursing, M., Dimmock, V., & Mulchandani, H. (2017). Error and root cause analysis. BJA Education. 10.1093/bjaed/mkx019

Rieder, M. (2018). Adverse drug reactions across the age continuum: epidemiology, diagnostic challenges, prevention, and treatments. The Journal of Clinical Pharmacology58, S36-S47.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2020). Medication dispensing errors and prevention. StatPearls: Treasure Island, FL, USA.

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