Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).
Complete the root cause analysis worksheet to analyze the case.
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.
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.
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.
Expert Solution Preview
The multifactorial medication mishap case study highlights the importance of medication safety in healthcare. As a medical professor responsible for creating assignments for medical students, it is vital to emphasize the significance of root cause analysis (RCA) in identifying the underlying causes of medication errors. This reflective summary will explore the appropriateness of using RCA in the given case study and the impact of using tools such as RCA, FMEA, and PDSA on the quality and safety of patient care.
Why Root Cause Analysis was Appropriate for this Situation:
RCA is a structured process used to identify the underlying causes of an adverse event or near-miss in healthcare. The multifactorial medication mishap case study was appropriate for RCA because it enabled healthcare providers to identify the root causes of the medication error and implement changes to prevent similar incidents from occurring in the future. The case study highlighted the complexity of medication prescribing and administration, emphasizing the need for a systematic approach to ensure medication safety. The RCA process in this scenario helped healthcare providers to identify the factors that contributed to the medication error, such as inadequate training on medication administration, complexity of medication prescribing, and the need for medication labeling to be more explicit. As a result of the RCA process, healthcare providers were empowered to make changes to the medication administration process, such as using more explicit labeling and reducing the number of medication options in the CPOE system, to prevent similar incidents from occurring in the future.
Impact of Using RCA, FMEA, and PDSA on the Quality and Safety of Patient Care:
The use of tools such as RCA, FMEA, and PDSA can have a significant impact on the quality and safety of patient care. RCA helps healthcare providers to identify the underlying causes of medication errors and develop strategies to prevent similar incidents from occurring in the future. FMEA is a proactive risk assessment tool used to identify potential failures within a system and develop strategies to prevent these failures. PDSA is a quality improvement tool used to test and implement changes in a systematic manner.
The use of these tools can have a positive impact on the safety and quality of patient care by providing a systematic approach to identifying and addressing areas of concern within the healthcare system. FMEA and PDSA can be used proactively to identify potential areas of risk and implement changes to prevent harm before it occurs, while RCA can be used retrospectively to identify the underlying causes of adverse events and near-misses in healthcare. The use of these tools can lead to improved patient outcomes, enhanced patient safety, and a reduction in healthcare costs associated with adverse events.
In conclusion, the multifactorial medication mishap case study highlights the importance of medication safety and the significance of RCA in identifying the underlying causes of medication errors. The use of tools such as RCA, FMEA, and PDSA can have a positive impact on the quality and safety of patient care by providing a systematic approach to identifying and addressing areas of concern within the healthcare system. As a medical professor, it is essential to teach students the importance of medication safety and the use of RCA in identifying the root causes of medication errors to prevent similar incidents from occurring in the future.