Week 4 Discussion – Root Cause Analysis

Composition of the RCA Team and What Knowledge They Contribute to the RCA
Based on this case scenario, the RCA team comprises the facilitator (quality assurance
person), the nurse manager, and the director of pharmacy. The QI expert is responsible for setting
the tone for analysis, including providing guidance on RCA tools and procedures, collecting and
analyzing data on the potential causes of the medication errors, ensuring other participants
collaborate, and implementing corrective measures. The nurse manager brings in-depth insight
into the clinical environment – patient care processes, practices, EMR usage, workflows, and
staffing issues – that might contribute to medication error. The director of pharmacy brings
information pertinent to the medication management procedures, protocols, processes, and
policies, from instruction review to drug dispensation and administration. He/she also brings
insight into CPOE and other technologies used in the pharmacy.
The Collaboration in the Case Study That Led to Effective Problem Solving
Collaboration is necessary for RCA processes to succeed. This is demonstrated in the case
study, with teamwork among RCA members (the nurse manager, the QI person, and the director
of pharmacy) playing an integral part in addressing medication errors. There are multiple
incidences in which collaboration is demonstrated. For example, on 15 th May, the QI team met
nursing staff to strategize; they jointly determined to use the IHI rapid cycle improvement
framework with iterative PDSA. On 15 th Oct, the two teams again collaborated to summarize
strategies and year-end progress.
The Team’s Process in Testing for and Eliminating Non-Contributing Root Causes
The first step in testing and emanating non-contributing root cases to medication errors is
defining the problem and gathering relevant data. This includes asking the how, when, and what

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questions. The second step is to analyze the data using RCA tools and techniques, such as the
fishbone, Pareto analysis, or process flow chart. Logic is required to identify the most pertinent
and relevant tool for analyzing the causes of medication errors cheaply, effectively, and quickly
(Singh et al., 2023). The final step is to recommend and implement the most appropriate
solutions.
Critique of the Cause-Effect Diagram (Fishbone), Including Its Effectiveness in Identifying
the Root Causes and Establishing a Solution to Prevent Repeat Medication Errors
The cause-effect diagram (fishbone) is without a doubt the most effective RCA tool for
establishing the causes of medication errors and potential solutions to prevent repeat incidences.
The fishbone is effective because it offers a more structured and visual representation of the root
causes of medication errors (Abdulai et al., 2020). As a collaborative tool, the fishbone allows
teams to map out, brainstorm, organize, and categorize the multiple causes of medication errors
visually. Teams can develop strategies and prioritize their implementation from these root causes.
Contributing Factors and How to Prevent the Error in the Future
Based on the case-effect diagram (fishbone), factors contributing to medication errors can
be classified into three: human factors stemming from the pharmacy (knowledge deficit on the
7Rs, staff burnout, and pharmacists being unavailable on the unit and unreachable on the phone),
human factors related to nursing (knowledge deficit of drug generic v. trade names,
understaffing, manual entry of patient data, and knowledge deficits on the medication Rs), and
equipment and supplies (scanners failing to scan and defective barcode scanners). A
multipronged approach that addresses all these contributing/causative factors is required to
prevent repeat errors. For example, pharmacists and nurses need training on the 7 Rights (patient,
drug, dose, time, route, reason, and documentation) to ensure safe drug preparation, dosing, and

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administration. The facility must hire more pharmacists and nurses to address burnout and
potential stress. An EMR is also required in the nursing department to improve efficiency and
accuracy in recording patient information. The current manual entry system is cumbersome and
prone to errors. Most importantly, the facility needs to repair, update, and upgrade its barcode
systems, ensuring they are working properly.

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References

Abdulai, M. N., Prah, J., Walker, E., & Afrifa, A. D. (2020). A fishbone analysis of the use of
electronic health records (EHR) in a primary healthcare setting: The case of University of
Cape Coast Hospital. International Journal of Applied Information Systems, 12(33).
Singh, G., Patel, R. H., & Boster, J. (2023). Root cause analysis and medical error prevention.
StatPearls [Internet].