Root-Cause Analysis of MAEs in the Medical-surgical Unit NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Root-Cause Analysis of MAEs in the Medical-surgical Unit

MAEs are the identified problem in the medical-surgical unit. They occur in various ways, including wrong patient, wrong drug, wrong dose, wrong route, wrong time, omission of doses, failure to document, and technical errors. Generally, MAEs are considered a failure in observing one of the five rights of medication administration: right patient, medication, dose, time, and route (Schroers et al., 2021). MAEs in the unit have been associated with adverse health outcomes, prolonged patient stay, increased morbidity rates, and healthcare costs. Besides, they reduce patient satisfaction and increase legal cases when patients sue health providers and the facility for perpetrating medication errors that negatively impact their health and quality of life (Schroers et al., 2021).

An RTA was carried out on 15 cases of reported MAEs that occurred in the medical-surgical unit over three subsequent months. The RTA was carried out by a team of four: the nurse in-charge of the unit, a quality improvement expert, a registered nurse from the unit, and a physician. Besides, the reported MAEs occurred in the form of the wrong patient, wrong drug, wrong dose, and wrong route of administration. Although no mortalities were associated with the MAEs, adverse drug effects, allergic reactions, prolonged patient stays, and increased healthcare costs were documented.

The causes of the MAEs were grouped into three: Knowledge-based factors, Contextual factors, and Personal factors. The RTA findings revealed that 10% of the nurses, mostly new graduate nurses, reported that the MAEs occurred due to knowledge-based factors. They include inadequate knowledge of medications and drug administration protocol, inadequate skills, dose miscalculations, and inadequate knowledge and skills to use drug administration technology like the electronic infusion pump. In addition, 95% of the nurses reported that contextual factors contributed to the MAEs.

The reported contextual factors included understaffing, heavy workloads, lack of time, work-related pressure, interruptions and distractions, language barriers, lack of supervision and support, and lack of training. All nurses reported that they were understaffed, overworked, and lacked sufficient time to attend to a patient when administering treatment adequately. This creates a lot of work pressure, creating room for numerous MAEs as the nurses do not concentrate on the drug and dosage they administer to patients (Schroers et al., 2021). Furthermore, the nurses reported being physically exhausted, primarily due to working long shifts and not taking adequate breaks or lunch.

New graduate nurses expressed concern over the lack of supervision and support from their supervisors, which increases work pressure causing mental distraction, and MAEs. Besides, 18% of the new grad nurses reported that they were not oriented on medication administration, which contributed to poor decision-making when administering medications and medication errors. Interruptions and distractions during drug administration were reported by 90% of the nurses. In the reported MAE cases, the nurses stated that they got interrupted when administering medication by other patients or their supervisors and were forced to do another task and, as a result, gave a drug to the wrong patient or administered the wrong drug or dose.

Personal factors were also identified in 40% of the MAE cases, including negligence, psychological stress, lack of confidence in approaching physicians to clarify an order, inattention when administering medication, tendency to make assumptions, and intentional deviations from protocols. Complacency was a major factor, with 75% of the nurses reporting that they tend to make assumptions mainly related to the nurses’ second-check of medication (Schroers et al., 2021). Besides, nurses admitted to making assumptions about the prescribed medications when the written prescription was not clear rather than consulting with the prescribing clinician resulting in the administration of the wrong dose and route. Furthermore, fatigue and physical exhaustion were also reported as personal factors causing MAEs by the nurses.