15 Mar Review the case scenario included in this weeks media resources, and examine the process flow chart, cause/effect diagram, and
Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.
I have attached a copy of the instructions, the transcript for the scenario, the flowsheet and pareto chart.
Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.
Post each of the following:
· Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.
· Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.
· Explain the team’s process in testing for and eliminating root causes that were not contributing.
· Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.
· Identify the contributing factors and discuss how to prevent this kind of error from occurring in the future.
,
START
CPOE- COMPUTERIZED
PHYSICIAN ORDER ENTRY
PHARMACY TECH CHOOSES MED OFF THE SHELF
STOCKS UNIT DOSE CART
FOR PATIENT
NURSE CHOOSES MED FROM
UNIT DOSE CART
NURSE SCANS BARCODE
SCANNER SHOWS MATCH
MED ADMINISTERED USING 7 RIGHTS
ELECTRONIC DOCUMENTATION
VIA BARCODE
NURSE DOCUMENTS
ANY REACTIONS
NURSE MANUALLY ENTERS INTERNAL
ENTRY NUMBER
MATCH?
NURSE CALLS PHARMACY
SITUATION CLARIFIED?
NURSE CALLS SUPERVISOR
FOR GUIDANCE
END
PROCESS FLOW CHART: MEDICATION ADMINISTRATION
DOWNTOWN MEDICAL
YES NO
YES NO
YES
,
# ERRORS
272
238
204
170
136
102
68
34
VITAL FEW
USEFUL MANY
102 60 60 20 15 8 7 0
37%
59%
82%
89%
94%
97% 100%
100% DE
FE CT
IV E
SC AN
N ER
S
LO O
K- AL
IK E
M ED
IC AT
IO N
L AB
EL IN
G
PH AR
M AC
Y TE
CH ST
RE SS
/E RR
O R
M AN
UA L
EN TR
Y IN
TE RN
AL E
N TR
Y N
U M
BE R
N O
P H
AR M
AC Y
RE SO
U RC
E PH
O N
E O
R VO
IC EM
AI L
KN O
W LE
DG E
DE FI
CI T:
7 RI
GH TS
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RS IN
G
KN O
W LE
DG E
DE FI
CI T:
GE N
ER IC
T RA
DE N
AM ES
KN O
W LE
DG E
DE FI
CI T:
PH AR
M AC
Y TE
CH S
BA RC
O DE
L AB
EL S
PR O
BL EM
LA CK
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PH AR
M AC
IS T
RO U
N DS
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DO W
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0 0 0 0
PARETO CHART: MEDICATION ERROR ANALYSIS 2015 DOWNTOWN MEDICAL
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RCA Dramatization 1
RCA Dramatization 1 Program Transcript
FEMALE SPEAKER: Medication errors are a plague. As in the case you're about to see, it involves a 20-bed medical treatment facility called Downtown Medical. Everyone at the facility had believed that medication errors would decline there for two reasons. First, they started utilizing computerized physician order entry, or CPOE, in conjunction with online nursing documentation, NDMR. And also, they began employing barcoded medication administration.
But after four years of using these tools, there are still issues. Another medication error has occurred. In fact, there have been many, constituting a significant pattern and trend. So an RCA team has been assembled. The team is comprised of me– I'm the risk manager– Pamela Brown, the staff nurse, and Matthew White, our pharm tech. We called our first meeting. And this is what happened.
This medication error could have easily happened to anyone in our hospital. Our responsibility is to prevent it from happening again. This is the eighth medication error this month. We have to determine the cause of the errors.
FEMALE SPEAKER: I agree, Linda. But if I could be direct for a second, I think if pharmacy got their act together, we wouldn't be having any of these problems.
MALE SPEAKER: You don't want to start pointing fingers, Pam.
FEMALE SPEAKER: Look, we've all had our share of problems with this issue. And we're all on the hook for patient safety. We have to get at the root cause of what's happening here. And that's why I picked you for this team. I need you to keep an open mind on this.
FEMALE SPEAKER: You're right. I'm sorry I made that comment, Matt.
MALE SPEAKER: No problem.
FEMALE SPEAKER: The thing is my nurses are always so stressed and understaffed. We hear complaints all the time about patient safety, like it's all on us. The truth is the pharmacy at Downtown Medical really is quite helpful. I mean that.
MALE SPEAKER: Thank you. What Pam said, the same thing is true in the pharmacy. I've been a pharm tech here for 10 years, and it feels like we're always understaffed. We never seem to have enough people. Maybe we should start by talking about that?
© 2016 Laureate Education, Inc. 1
RCA Dramatization 1
FEMALE SPEAKER: That's a good idea, but I thought we'd look at the overall process first, from start to finish. Have either of you ever developed a process flow chart?
FEMALE SPEAKER: I've read about them. But I've never done one.
MALE SPEAKER: Well, I was in on the last IT install. We did process flow charting for that.
FEMALE SPEAKER: OK. So what I thought we'd do is use this first meeting to scope out how the process works. We'll write it out. After that, you should take it back to your departments and use it to conduct interviews with those who were involved with the actual medication error incident. And then we'll use it on our next meeting. Is that OK with you?
MALE SPEAKER: Works for me.
FEMALE SPEAKER: Yeah, me, too.
FEMALE SPEAKER: OK. Great. Then the next step will be to identify individuals we'll want to interview to determine exactly what happened with the medication error. We'll be constructing a cause effect diagram, which is a qualitative tool done with some brainstorming after the interviews. And we'll be analyzing last years medication errors as to primary cause. We'll need weekly meetings and some ground rules to pull this off. Are you game?
The meeting got off to a bumpy start, but once we focused on working together, the RCA team members were true to their word. They kept an open mind and agreed to meet on a regular basis to get the work done. In no time, they helped me complete the process flow chart, a cause and effect diagram, and a complete analysis of a year's worth of medication errors, which were plotted on a Pareto chart. We were on our way.
RCA Dramatization 1 Additional Content Attribution
FOOTAGE: GettyLicense_113439900_h12.mov Chayne Gregg/Creatas Video/Getty Images
© 2016 Laureate Education, Inc. 2
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