Root-Cause Analysis and Safety Improvement Plan-Improper Dosing

Root cause analysis is a systematic process of discovering the root causes of a problem using a wide range of techniques to identify possible address interventions. Root cause analysis of improper dosing and other medication-related errors seeks to discover various causal factors and identify possible solutions. A root cause analysis of improper dosing was conducted at the ED of a Diabetic clinic. This paper analyzes improper dosing, as a safety issue, with emphasis on the root causes, evidence-based strategies to address them, safety improvement plans for improper dosing, and the organizational resources that can be leveraged to ensure safe medication administration.

Root Cause Analysis of Improper Dosing

Improper dosing may be in the form of extra dosing, underdose, or overdose. Cavell & Mandaliya (2019) defines improper dosing as an event that occurs when a patient is given a medication with an inappropriate dose, a dose different from what was ordered, or through the wrong route of administration. Improper dosing can result in serious health complications. Organ damage, allergic reactions, and even death may arise when drugs are administered in incorrect doses. Whenever they occur, improper dosing prolongs hospital stay days for patients, increases the rate of hospital admission and readmission, and lowers the quality of life of an individual. The resultant healthcare burden underpins the need to address them.

The root cause analysis was conducted at the ED of a diabetic clinic after a diabetic patient developed severe hypoglycemia with resultant seizures and confusion after being given insulin. The lead nurse detected this problem and initiated corrective measures for the patient. This problem involved a nurse intern and a nurse on rotation at the clinic. The hospital’s medical team, consisting of a pharmacist, a physician, and the lead nurse, conducted the analysis.

Analysis of the event revealed that the insulin was administered via the wrong route. While the prescription order indicated that the insulin was to be given through a subcutaneous route, the nurse administered the drug intravenously. The wrong route of administration is a causal factor for improper dosing. Several influences were implicated as causal factors for the nursing error that led to the event. Inexperienced staff, fragmented communication, fatigue attributable to the high volume of patients, and shift work were all implicated in the event. Inexperienced staff is a risk factor for nurse-related medication administration errors. Dehvan et al. (2021) report that the prevalence of medication errors among nursing students remains high. This is attributable to their little experience and inadequate knowledge of medications.

Fragmented communication between caregivers is another risk factor for medication administration errors. There was evidence of fragmented communication between the intern nurse, the pharmacists, and the nurse in charge. Communication gaps in healthcare impede information sharing and discourage constructive consultations that may help in the prevention of medical and medication errors. Up to 27% of medical malpractices are a consequence of fragmented communication and communication failures (Tiwary et al., 2019). This highlights the need for better communication.

Fatigue attributed to a high volume of patients and tight work shifts also plays a role in this case. The nurse reported doing double shifts to cover up for an earlier missed shift. Fatigue and nurse burnout attributable to high workload are causal factors for many nursing mistakes. Burnout is a significant predictor of medication administration errors (Aryankhesal et al., 2019). This highlights the need for staff rescheduling and staff addition as measures for lessening workload.

Application of Evidence-Based Strategies

Enhancing nurses’ experiences and knowledge of medication administration maintains effectiveness in lowering nurse-related medication errors. This can be attained systematically by increasing the duration of supervised contact between nurse students and the patients and expanding nurses’ training on medication. Mohammadipour et al. (2020) assert that blended learning remains an effective strategy for enhancing nurses’ knowledge of medication. This intervention can enhance nurse experience and knowledge of medications, lowering their likelihood of making errors.

Minimizing nursing fatigue and burnout can also help in reducing medication-related errors. This can be achieved through nurses rescheduling and improving the nurse-patient ratio to lower the workload on individual nurses, improving communication skills, encouraging teamwork and partnerships, and implementing support programs that help nurses cope with pressure (Aryankhesal et al., 2019). These interventions c