Multifactorial Medication Mishap-Root Cause Analysis

Multifactorial Medication Mishap-Root Cause Analysis

 

Multifactorial Medication Mishap RCA

Read the Multifactorial Medication Mishap case study and the commentary that follows. Link: https://psnet.ahrq.gov/webmm/case/314/multifactorial-medication-mishap

Write a 525 word-summary in which you:

  • Explain why a root cause analysis was appropriate for this situation.
  • Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.

Cite a minimum of two peer-reviewed or evidence-based sources published within the last three years to support your summary in an APA-formatted reference page.

Must: be original work as it will be ran through a plagiarism check.

I have attached the grading rubric along with the required worksheet to be completed.

attachment that describes how the 525 word summary should be formatted and the required heading. See attachment. Let me know if you have any questions.

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Answer preview

Medical errors in health organizations are quite common, and the causes are multifactorial. In the case study by Yang (2014), a bedside nurse administered 2.5 mL (50 mg) to a patient instead of 0.25 mL (5 mg) of liquid oxycodone. The mistake the nurse did was relying on her memory instead of following the pharmacist’s instructions. Further, the pharmacist failed to give the medication in a standardized dosage. Also, neither the physician, nurse, nor the pharmacist knew about the patient’s medication history. Hence, this was the root cause of all the medical errors that the treatment team made. Medical errors can lead to harmful effects; therefore, implementing a root cause analysis (RCA) could assist in identifying underlying errors in healthcare to avoid adverse implications.

Explain Appropriateness of Root Cause Analysis for this Situation

Based on the case study, an RCA would be appropriate for this situation since it would assist the management in establishing…

(600 words)
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