Root Cause Analysis
RCA Dramatization 1 RCA Dramatization 1 Program Transcript FEMALE SPEAKER: Medication errors are a plague. As in the case you’re ab\ out to see, it involves a 20-bed medical treatment facility called Downtown \ Medical.
Everyone at the facility had believed that medication errors would decli\ ne there for two reasons. First, they started utilizing computerized physician or\ der entry, or CPOE, in conjunction with online nursing documentation, NDMR. And als\ o, 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 signif\ icant pattern and trend. So an RCA team has been assembled. The team is compri\ sed 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 hap\ pened.
This medication error could have easily happened to anyone in our hospit\ al. 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 prob\ lems.
MALE SPEAKER: You don’t want to start pointing fingers, Pam.
FEMALE SPEAKER: Look, we’ve all had our share of problems with this issu\ e.
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 helpfu\ l. 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?
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1 RCA Dramatization 1 FEMALE SPEAKER: That’s a good idea, but I thought we’d look at the overa\ ll 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 i\ t 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 i\ t 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 indivi\ duals we’ll want to interview to determine exactly what happened with the medi\ cation error. We’ll be constructing a cause effect diagram, which is a qualitat\ ive tool done with some brainstorming after the interviews. And we’ll be analyzin\ g 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 tog\ ether, 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 co\ mplete 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:
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