Sign In
Not register? Register Now!
Pages:
2 pages/β‰ˆ550 words
Sources:
Check Instructions
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 8.64
Topic:

Multifactorial Medication Mishap: The Root Cause Analysis

Essay Instructions:

This is a two fold assignment. I am not sure how to submit the 2nd part. Please advise
Two Part Assignment:
Root Cause Analysis.
Summary paper.
The Link to Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network). https://psnet(dot)ahrq(dot)gov/web-mm/multifactorial-medication-mishap
Multifactorial Medication Mishap Case Study:
The Case A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty. The nurse informed the physician that the patient was having significant pain and liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list — two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation).
At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product and ordered a 5-mg dose. All medication orders at the hospital had to be verified by a pharmacist. The pharmacist reviewing this order recognized that the higher concentration was atypical for inpatients but assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist verified the order and, to minimize the risk of error, added a comment to both the electronic medication administration record (eMAR) and the patient-specific label that the volume to be given was 0.25 mL (5 mg). For added safety, the pharmacist personally retrieved, labeled, and delivered the drug and a calibrated syringe to the bedside nurse to clarify that this was a high concentration formulation for which the volume to administer was 0.25 mL (a smaller volume than would typically be delivered).
Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she was more used to giving, and then left for her break. A covering nurse checked on the patient and found him unconscious — a code blue was called. The patient was given naloxone (an agent that reverses the effect of opioids), and he responded well. He was transferred to the intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the effect of the oxycodone. By the following morning, the patient had returned to his baseline with no apparent adverse effects.
Format submit both files:
Write a 525-word, APA 7th summary in which you:
What is a root cause analysis.
Why is/are root cause analysis performed?
Explain why a root cause analysis was appropriate for this [case study] situation.
Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.
Summary - What did you learn and how will you apply the knowledge.
Attach the root cause analysis with your paper or add as an *appendix to your paper.
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.
Submit your worksheet and summary.

Essay Sample Content Preview:

Multifactorial Medication Mishap RCA
Student
Institution
Course
Professor
Date
Multifactorial Medication Mishap RCA
A root cause analysis (RCA) describes the different approaches, techniques, and tools that are used to uncover the causes of a certain challenges. Some RCA methods are intended to uncover the cause of the problem, which other are problem-solving approaches that are intended to support the central activities of the RCA. RCA is also an aspect of Total Quality Management, which is essential to ensure that there are quality control measures within an institution. Whenever an RCA is performed effectively, the key points of development in the operations or processes causing defects are noted. The people responsible can apply corrective measures to safeguard the institution from further losses (Fassett, 2011).
There are numerous benefits associated with RCA. First, RCA is enables institutions to understand the main cause of defects on challenges in a business process. This is proper basis for ensuring that quality is attained. RCA can also be a means to reduce costs and identify failure. The problems arising in any processes are also associated with financial losses. This is because more costs are incurred during the process of repairing or addressing the defects. RCA also addresses questions related to failure sources. The team can seal existing gaps and leverage on other aspects to warrant continuous growth (Fassett, 2011). RCA is also essential for improving safety and reliability of procedures. By performing RCA, individuals can highlight the defects within systems and improve them for the future. This is beneficial in setting where quality is important and product reliability is essential. Through RCA, organization are able to enhance the value of the products and services. This makes marketing process easier to implement and follow. When defects are highlighted, all corrective measures are...
Updated on
Get the Whole Paper!
Not exactly what you need?
Do you need a custom essay? Order right now:

πŸ‘€ Other Visitors are Viewing These APA Essay Samples: