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Root-Cause Analysis and Safety Improvement

This report delves into a significant medication administration error at Tampa General Hospital (TGH), a prevalent issue that critically impacts patient safety. As a backdrop, medication errors rank as a leading cause of preventable harm in healthcare settings. Through this assessment, we will systematically explore the root causes behind such errors at TGH using Root-Cause Analysis (RCA). Subsequently, we will propose best practice strategies to mitigate these challenges, devise an evidence-based safety improvement plan, and identify organizational resources to bolster this plan’s success.

Analysis of the Root Cause

 Several medication administration errors occurred at Tampa General Hospital, but the incident with a 45-year-old patient, Hannah, instigated the use of RCA. Hannah underwent appendix surgery and was admitted for her post-surgery recovery. In one of the nurses’ rounds for medication administration, Hannah was administered the wrong medication by nurse Olivia. Hannah’s doctor had prescribed her morphine, ciprofloxacin, and heparin. The nurse examined her prescribed medications and went to the dispensing unit. Meanwhile, she received a phone call and started talking casually while dispensing medication from the automated dispensing system (ADS).

The ADS system faced glitches and dispensed the wrong medicines. Olivia was momentarily distracted by a phone call and paid no attention to the dispensed drug. She administered a double dose of heparin instead of morphine. This resulted in massive bleeding in the patient. This problem was detected by the nurse, Olivia, as she saw her patient bleed significantly. She immediately reported to an emergency, and Hannah’s bleeding was controlled.