Multifactorial Medication Mishap

Medication Mishap Root Cause Analysis Worksheet
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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 steps in the intended process flow entail the following steps
* The verification of the site
* The instruments used in the procedures
* Identification process (for patients)
* Patient assessment process
Risks and prevention protocol.

Lack sufficient training for the medical staff

Were there any steps in the process that did not occur as intended?

Explain in detail any deviation from the intended processes.

* The verification refers to the pre-procedures. It also entails educating patients on the side effects of surgery.
* Instruments used in the procedures ought to be determined before the procedure to avoid complications
* Patient identification protocol involved registering at least two names of the patient
* Patient assessment is very critical since it helps in determining the right medication after the procedure. For example, a 50-year-old was given the wring medication since he was no assessed after the procedure.
Nurses identified the risks associated with opioids to the patient and improvised a prevention technique.

Verification protocol not adhered as required

What human factors were relevant to the outcome?

Staff-related human performance factors such as fatigue, distraction, etc.

* Failure to establish the right procedures for the patient contributed highly to the outcome
* Exhaustion and fatigue on the nurse in charge contributed to the outcome
* The outcome might also have been contributed by information bias
Some nurses do not have extensive skills when it comes to critical thinking. With that, they will follow odd procedures without assessing the patient.

Exhaustion and fatigue

How did the equipment performance affect the outcome?

Consider all medical equipment and devices.

* Inappropriate use of disinfectants such as hydrogen peroxide and phenolics might have contributed to the outcome.
* Surgery equipment was not sterilized well, which could cause a problem.
* Other devices that are used externally, such as an external defibrillator, AED devices, might contribute to the outcome if they are not handled appropriately.
Mostly, staff did not have adequate knowledge about the devices (after and before procedure device).

Lack of appropriate equipment

What controllable environmental factors directly affected this outcome?

Consider things such as overhead paging that cannot be heard or safety or security risks.

* Some of the environmental factors affecting the outcome include visitors.
* Invisible medical equipment, for example, all instruments that use scale and calibration.
Over the page is another factor that contributed to the outcome. Typically, over-paging is a communication system in hospitals. There was foul communication...