Root-Cause Analysis and Safety Improvement Plan of Vibra Hospital Medication Error

Root Cause Analysis and Safety Improvement Plan
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Root Cause Analysis and Safety Improvement Plan – Vibra Hospital Medication Error

The Vibra Hospital is a long-term and acute care health facility based in Sacramento, California. In 2014, a patient died at the facility after administering an excessive dose of Levophed (Anderson, 2019). While the medication type was correct, the administered dosage was significantly higher, up to 8,000 times the required amount. The current paper analyzes the root cause of the error and provides an actionable plan to improve the safety of patients.

Analysis of Root Cause

According to the CDPH report (CDMH, 2014), following the incident, a nurse gave the patient 3,000 to 8,000 times the prescribed dosage of the Levophed drug. The drug was prescribed as part of the strategy to manage the patient’s blood pressure. Unfortunately, the patient’s heart stopped during the drug administration by a nurse on 14^th December 2014. As a result, the health facility was fined a maximum amount of $75,000 by the California Department of Public Health (CDMH).

The findings by the CDPH investigative team suggest that several factors might have led to the error. The first cause was that the nurse did not check the patient’s medical record to determine whether the current BP was at the level that would require the use of the medication as indicated by the doctor. Secondly, the medication was placed separately with the required IV pack. While the medication was placed in the dispensing machine, the IV pack was placed in the refrigerator. The administration of the drug requires dilution through intravenous drip infusion.

Further, where the medication was placed, there were no safeguards for high-alert medication (Rahhal, 2019). Additionally, the nurse reported that she had never administered the drug before and did not research it. Furthermore, a hospital policy in which a second nurse should co-sign...