Read and respond to the postings of two or more of your colleagues’ who discussed different

charts, identified different evidence of positive collaboration, and/or identified different

contributing factors than you did. Also offer comments that ask for clarification, provide support,
or contribute additional information. Offer alternative viewpoints on the cause as you see it.

Post a Discussion entry on three different days of the week.

Tammy Bennett
Apr 28, 2024 Apr 28 at 2:21pm

Various forms of knowledge can contribute significantly to the RCA (Root Cause Analysis)
process for medication errors within Downtown Medical. Clinical expertise from nurses and
pharmacy technicians can provide insights into administration procedures, including potential
points of error and strategies for improvement. Understanding human factors and ergonomics
can help identify issues related to workflow design, interface usability, and cognitive workloads,
which may contribute to errors despite technology such as computerized physician order entry
and barcode scanning. Additionally, knowledge of organizational culture and communication
dynamics can shed light on factors such as hierarchical barriers, lack of interdisciplinary
collaboration, or insufficient training, which may impede error prevention efforts.

Effective collaboration and problem-solving involve open communication, active listening, and
mutual respect among team members. The risk manager nurse and pharm tech collaboration
demonstrate these principles in this scenario. By engaging in collaborative techniques such as
process flowcharting, cause and effect diagramming, and brainstorming, the team can
collectively analyze the root cause of medication errors and generate inventive solutions.
Effective collaboration is evidenced by including diverse perspectives, the willingness to explore
multiple hypotheses, and the commitment to shared decision-making.

As healthcare embraces process improvement methods such as Lean, Six Sigma, and rapid-cycle
improvement from manufacturing and information technology industries, process mapping has
become a more prevalent tool and has begun to play a fundamental role in improving healthcare
quality and operational efficiency. (Heher et al. 2017)

A downfall to process flowcharting found in an article by Antonacci et al. (2021) noted that
variance in reporting and lack of compliance with guiding principles underpinning its effective
use might inhibit its full potential in healthcare improvement initiatives and in sharing learning
between initiatives. Greater scientific rigor in the application and reporting of PM is required to
increase its effectiveness as a method for improvement and advance the field of improvement
science.

When facing challenging problems, many organizations rely on idea-generation sessions (e.g.,
brainstorms) to develop creative ideas and solutions. (Ritter et al. 2018)

Furthermore, effective collaboration is characterized by an emphasis on system improvements

rather than blame attribution. Though initially, the nurse did place blame on the pharmacy, with
the assistance of the risk manager, refocusing the team, the RCA team focused on understanding
the underlying factors contributing to medication errors rather than assigning fault to individual
healthcare professionals. This approach fosters a culture of psychological safety, where team
members feel comfortable reporting errors and participating in proactive risk mitigation efforts
without fear of retribution by emphasizing learning and improvement. The RCA process
promotes a culture of accountability in continuous quality improvement within this medical unit.

Antonacci, G., Lennox, L., Barlow, J., Evans, L., & Reed, J. (2021). Process mapping in
healthcare: a systematic review. BMC health services research, 21(1), 342.
https://doi.org/10.1186/s12913-021-06254-1

Links to an external site.

Heher, Y. K., & Chen, Y. (2017). Process mapping: A cornerstone of quality

improvement. Cancer Cytopathology, 125(12), 887–890. https://doi.org/10.1002/cncy.21946

Links to an external site.

Ritter, S. M., & Mostert, N. M. (2018). How to facilitate a brainstorming session: The effect of
idea generation techniques and group brainstorming after individual brainstorming. Creative
Industries Journal, 11(3), 263–277. https://doi.org/10.1080/17510694.2018.1523662

Collapse Subdiscussion Danielle Capp

Danielle Capp
Apr 29, 2024 Apr 29 at 2:08pm

Main Discussion:

Downtown, a treatment facility decided to conduct a medication error root cause analysis (RCA)
due to the continual increase in errors even after implementing computerized physician order
entry sets, online nursing documentation in their electronic medical records, and barcode
medication entry (Walden University, 2016a). The facility gathered a pharmacy technician, unit
RN supervisor, and the risk manager and created the root cause analysis team. These individuals
will conduct a root cause analysis, which aims to investigate all near misses and possible causes
of all adverse events and identify ways of prevention (Charles et al., 2016).

The RCA method looks beyond the human error element and analyzes the system process,
looking for contributing factors causing continual medication errors. The risk manager functions
as the chair of the RCA team and helps facilitate and provide guidance to all team members on
implementing the RCA method's steps within their individual service units. The facility’s
pharmacy technician is vital to the team in providing insight into how the medication delivery
system is filled and how medications are dispensed to individual patients and facility units. It is
also vitally important to have the full-time unit RN as a team member, as she is adept at how
medications are administered and how the barcoding system functions and is utilized (Walden
University, 2016b). Together, the team members have a collective wealth of knowledge.
Initially, the body language of both the pharmacy technician and nurse communicated verbally
and non-verbally some destructive and defensive messages regarding stress levels and staffing
issues. The risk manager displayed effective leadership in recognizing this and validating both
individuals’ concerns while validating the concerns, setting clear boundaries and providing
concise directions to ensure objectivity while conducting the RCA (Yoder, 2019).

To effectively carry out the RCA, the team developed a process flow chart to record the process
flow and any events leading up to the adverse event. This process flow chart is a helpful tool
initially and later in the analysis as it can identify new processes for improvement. Next, the
team conducted interviews with all the individuals involved. This allowed for the collection of
qualitative data from the interviews and brainstorming sessions to construct the cause-and-effect
diagram and a Pareto chart (Spath, 2018).

The process flow chart serves as the springboard for analyzing medication errors. However, the
fishbone diagram serves as the backbone for identifying the problem, any causative conditions,
and causative actions (Charles et al., 2016). In this case scenario, human factors in pharmacy and
nursing and environmental aspects of equipment and supplies all contribute to medication errors.
Analyzing the fishbone diagram highlights the increased stress levels and low staffing ratios for
nursing and pharmacy. Burnout may be the cause of the lack of accessibility to the pharmacy and
increased levels of stress and frustration in nursing. Nurses are struggling and need training on
generic versus brand name medications and direction on manually entering data into the barcode
system. The continual failure of scanners, machinery, and barcode labels contributes to errors in
nursing and pharmacy.

Finally, corrective actions may include checking the legibility of labels on medications and
wristbands and educating nurses on troubleshooting scanners and machinery when they are not
working (Yen et al., 2015). Other corrections include in-services for nursing and pharmacy on
the rights of medications, look-and-sound-alike medications, and brand versus generic names.

References:

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., Biermann, J. S., &
Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of
medical errors: A review. Patient Safety in Surgery, 10. https://doi.org/10.1186/s13037-016-
0107-8

Links to an external site.

Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Health Administration
Press.
Walden University, LLC. (2016a). RCA dramatization 1. Walden University Canvas.
https://waldenu.instructure.com

Walden University, LLC. (2016b). Root cause analysis at Downtown Medical. Walden
University Canvas. https://waldenu.instructure.com

Yen, Y. T., Chang, S. F., Tsai, K. L., Chen, C. J., Liu, L. C., & Fang, Y. C. (2015). Hu li za zhi
The journal of nursing, 62(6), 90–97. https://doi.org/10.6224/JN62.6.90

Yoder, W. P. S. (2019). Leading and managing in nursing (7th ed.). Elsevier.