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%

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0 0 0 0

PARETO CHART: MEDICATION ERROR ANALYSIS
2015 DOWNTOWN MEDICAL

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
f