Introduction

Medical transcription mistakes can lead to disastrous consequences. I came to be aware of this fact when I worked in a long-term care center. An unfortunate incident occurred when the patient’s prescribed Prednisone was not properly withdrawn after 30 days despite the prescription that said it was to continue for a long time. While I was not directly responsible for the error, I worked closely with three nurses, as well as with the physician involved in the mistake. This article will explore the way in NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan revealed that the death of the patient could have been prevented If the prescription was properly handled.

Root Cause Analysis Overview

One study has defined the term Root Cause Analysis (RCA) as a method of identifying the root reasons and the contributing factors to incidents or mistakes. Healthcare has changed its focus away from blaming individual staff members for errors to analyzing the systemic flaws that can lead to errors. I agree with the notion that RCA is the most efficient method of determining the reason for which an incident happened and for adopting appropriate preventative steps. According to studies, medical errors typically stem from a variety of causes, including poor communication and healthcare organizations that have weaknesses as a system (Najafpour, 2016).

The Case of Carl

For the purpose of this report, the person is referred to in the following manner “Carl.” Carl was admitted to the hospital to undergo physical rehabilitation after an extended hospitalization. He was a friendly elderly man who frequently felt exhausted, and his loving wife was there almost every day. NURS FPX 4020 Assessment 2 primary goal during his time in The facility was reduce the breathlessness he experienced and increase his tolerance to activity.

NURS FPX 4020 Assessment 2 Carl’s UnProblematic

Carl’s stay was relatively unproblematic, aside from occasional bouts of breathing problems when he changed from bed to a wheelchair. However, his condition suddenly became worse. Over the course of several months, Carl became weaker, stopped engaging in physical activity, and spent the majority of the day in his bed. The state of his mind deteriorated to the point that it was impossible for him to talk in complete sentences. Carl was a patient who carried MOLST forms indicating Do Not Resuscitate (DNR) and Do not Intubate (DNI) orders and died a couple of days afterward.

Following Carl’s passing, several employees, such as myself, wondered whether the cause of his death was caused by natural causes or an underlying problem.

Discovery of the Error

After the death of Carl, Two nurses from the unit and a nurse, Nurse A, started meetings in conjunction with Nursing Supervision regarding the incident. NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan was later discovered that the death of Carl was due to a transcription error related to his prescription for Prednisone. Prednisone, a corticosteroid, is used to treat various chronic ailments, such as inflammation and autoimmune diseases, asthma, as well as other autoimmune disorders (Vallerhand, 2017).

A review of documents showed that Carl’s Prednisone prescription was withdrawn in a way that was not appropriate. In NURS FPX 4020 Assessment 2 circumstances, corticosteroids like Prednisone are best taken off slowly; abruptly stopping them could result in adrenal dysfunction and could result in a life-threatening situation (Vallerhand 2017, 2017).

Related Assessment: NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Dr. B, one of the physicians contracted by the hospital, found the error when he was examining Carl’s medical records. Two months prior to Carl’s death, the doctor. A, Carl’s primary physician, had revised the prescription, removing “discontinue after 30 days” in the Provider Communication book, intending the medication to last for an indefinite period. However, Nurse A was not aware of the directions and entered an incorrect discontinuation date in the Electronic Health Record (EHR) system.

Carl’s wife was notified of the error but decided not to seek an action in court against the institution, a choice that shocked many employees.

NURS FPX 4020 Assessment 2 Improvement Plan and Evidence-Based Strategies

To avoid these tragedies, an effective improvement plan must address the reasons that contributed to the mistake. The most significant problem was the facility’s reliance on the Provider Communication book. The system is susceptible to confusion due to handwriting that is not legible or confusing symbols. Furthermore, Nurse A, who was tasked with administering medication to around 20 patients a day in addition to other duties, was not receiving sufficient assistance from nursing Supervision.

Recommendations for Policy Changes

1. Eliminating the provider communication, BookThe facility must transition to an electronic system of documentation for all prescriptions from the provider and reduce the chance of errors caused by mistakes in writing or communication. The research supports this method. One study showed that the introduction of an electronic discharge Medication Reconciliation Tool (EDMRT) dramatically reduced the number of errors in medication in hospital discharges (Allison, 2015).
2. Adopting an Electronic Prescribing System
3. A digital prescribing system can help reduce errors caused by inaccessible handwriting or confusion among similar-sounding drugs. Although no system is 100% foolproof, These tools may complement the judgment of a physician to increase accuracy (Hinojosa-Amaya, 2016).
4. Enhanced Supervision and Training
5. Nursing Supervision needs to be more involved in evaluating orders as well as supporting LPNs such as Nurse A.
6. Patient and Family Education
7. The process of educating the family members of clients on the potential side consequences of medications prescribed will help you identify any potential problems early. RNs, rather than LPNs, are the ones who should be responsible for providing this information because it falls within their area of expertise.

Implementation Strategy

The facility must collaborate in conjunction with their EHR provider to allow physicians to electronically enter orders. This integration can take between two and three months to roll out across the company. Utilizing existing staff members, such as RNs for supervision and education will make the plan more feasible.

Conclusion

Implementing these suggestions can improve the safety of patients and avoid incidents. In NURS FPX 4020 Assessment 2 Root-Cause Analysis transitioning to an electronic system for documentation, offering assistance to nursing staff, and focusing on the importance of education for families and patients, The facility will create a more secure and efficient atmosphere. While systemic changes take some time and effort however the benefits for client care are immense. 

References

Allison, G. M., Weigel, B., & Holcroft, C. (2015). Does electronic medication reconciliation at hospital discharge decrease prescription medication errors? International Journal

of         Health Care Quality Assurance, 28(6), 564-573. doi:http://dx.doi.org.library.capella.edu/10.1108/IJHCQA-12-2014-0113

Hinojosa‐Amaya, J. M., Rodríguez‐García, F. G., Yeverino‐Castro, S. G., Sánchez‐ Cárdenas, M., Villarreal‐Alarcón, M. Á., & Galarza‐Delgado, D. Á. (2016).

Medication errors: Electronic vs. paper‐based prescribing. experience at a tertiary care                         university hospital. Journal of Evaluation in Clinical Practice, 22(5), 751-754.

doi:10.1111/jep.12535

Najafpour, Z., Jafary, M., Saeedi, M., Jeddian, A., & Adibi, H. (2015;2016;). Effect size of contributory factors on adverse events: An analysis of RCA series in a teaching

hospital.                        Journal of Diabetes and Metabolic Disorders, 15(1), 27. doi:10.1186/s40200-016-0249-3

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Corticosteroids. In H. G.

Mansell (Contributing Ed.), Davis’s Drug Guide (15^th ed.). F.A. Davis

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