Root Cause Analysis: Medication Error

hi and welcome to our our CA lessons learn series today's issue will be on a medication error where the RN administers the wrong medication to the patient this will be a root cause analysis case study overview your presenters today will be myself Robert J Latino and best Boynton let's get started that the summary of the case overview will be about lorazepam one milligram tablet being administered by the RN instead of the correct medication which was clonazepam one milligram tablet I'd like to give short bio of each of the presenters today we have Beth Boynton with us this is a national speaker trainer executive coach and author of the book confident voices the nurses guide to improving communication and creating positive workplaces best information will be at the end if you need to contact her for any questions regarding this presentation and you can learn more about her at the URLs provided below my name is Robert Jay Latino and I am a career root-cause analyst and I specialize in the areas of RCA failure modes and effects analysis and reliability engineering I have four books to my credit that I have listed here and my information will also be at the end of this presentation should you have any questions regarding the root cause analysis processes okay let's move forward I'm going to turn it over now to Beth who's going to give us the case background Beth thanks Bob this medication error took place on a 20 bed dementia unit that asked with one registered nurse and RN and two licensed nurse assistants LNA at the time of the incident there were 19 residence locations full staffing would have included an additional Ln a shared with a neighboring unit of similar size mrs. Jones an elderly patient with dementia as a physician's order to receive clonazepam one milligram at 8:00 a.m. and 4:00 p.m. that was prescribed for Kwon anxiety she had been receiving lorazepam one milligram at the same time for several months and it had become ineffective for managing continual yelling and agitation the lorazepam had been discontinued two weeks earlier by her physician at the same time the clonazepam was started both of these drugs are controlled substances they have dispensed from the pharmacy and punch cards and kept with other narcotics and a ee los draw on the medication car the punch card with clonazepam was directly behind the punch card with a lorazepam's and at the end of the row of 25 punch cards with different controlled substances for different patients the error was found at the end of the nurses shift at 11:00 p.m. when the narcotics count showed an extra clonazepam and a missing lorazepam count occurs each change of shift when the nurse coming on duty count the actual pills and other substances in the doubly locked narcotics draw and the nurse leaving duty checks each number with that recorded in the Controlled Substances book when the medication error was discovered the physician and family were notified the patient had a typical day showed no signs of harm and the nurse completed an incident report according to protocol and I'll give it back to you Bob to demonstrate the root cause analysis process Thank You Beth okay today I'm going to only have one slide it's going to be brief as a summary of what you're about to see and how the analysis was conducted using what we'll call a logic tree what I'd like you to understand is that in the lower right hand corner of each block there's a little post-it and each will have a label of some type the e in this case is the event or the last effect of the cause-and-effect chain it's what called us into action the M is the mode it's the actual incident itself that led to that consequence in the event and then when we get to the modes we're going to ask how could that mode have occurred and this is going to spark the need for hypotheses as you'll see on the level below you'll see that we have the H which is hypotheses and when we have evidence to prove or disprove these either way than the ones that are disproven will receive an X and the ones that are proven we will continue to ask the hell can questioning let's go ahead and get started looking at our logic tree in this particular case okay I've left up a legend up here to my left so that you can see what some of these labels mean as we proceed down the logic tree our event in this case is an unacceptable risk of patient harm this was due to the unsafe administration that we've described previously now let's ask the question how could we have had an unsafe medication administration this brings us to what we call the five wrongs these are the five possibilities wrong time wrong person wrong dose wrong drug and wrong route you'll notice in the lower left hand corner is we have a number that ranges from a zero to a five this is what we call a confidence factor it's a it's where a the evidence that we have at hand either will prove or disprove that particular hypothesis zero means with the evidence we have this is not true a five means with the evidence we have this is conclusively true for instance on the wrong drug if we were to double-click on this hypothesis we see that we have a verification log in here at the end of the shift six hours later a review of the narcotics count that was our verification method the outcome the narcotics count was off there was an extra lorazepam and one missing clonazepam so just realize that as we move down this logic tree that all of these have been validated and that's the ones that are proving to be true are the ones that were following how could we have had the wrong drug these are the possibilities provided the drug was discontinued the wrong drug was placed adjacent to the correct drug the abnormal number there was an abnormal number of interruptions or distractions on that shift improperly labeled drugs prescription error and what we'll call normalization of deviance which I'll describe in a little bit so the ones that proved to be true where the drug was discontinued if I continue down and I asked how could the drug have been discontinued thus allowing us to administer it there was no space the place to discontinue drugs on the cart for controlled substances it was another hypothesis was the discontinued drugs were sent to the nurse that was proven not to be true and then we have discontinued drugs permitted to remain on the cart let's follow the ones that were proven to be true no space to place the discontinued drugs on the court for controlled substances how can that be hypotheses the policy exists and was followed was not true the policy exists and was not followed proves not to be true a policy does not exist which was this case or the policy was inadequate which was not true the policy does not exist this is a quality control issue or a Nellore which we will call a latent root cause this is a systemic root cause that impacts our decision-making there was no policy and procedure to handle discontinued drugs in the cart discontinued drugs permitted to remain in the cart how can that be either the policy does not exist or the policy does exist and we were in violation which was the case how can that be automatic reflex it became a common practice we don't think twice about it anymore because we do it so often how can that become a common practice it's an incorrect assumption that it's the way to do things it's like on-the-job training where people are telling us well this is the workaround that we've developed over the years and this is the way we do things it just becomes the way we do business and oftentimes these automatic reflexes and these workarounds or due to the fact that we're time pressured whenever we have a time pressure are placed upon us and we are more apt to take shortcuts and that's how these practices evolve and then the need for the time pressure comes from a general understaffing on the unit at that time which forces these types of behaviors okay let's move up to the next one that we had proven to be true the wrong drug was placed adjacent to the correct drugs how can that be the staff was not trained on how to prevent mix-ups why was the staff not trained on how to prevent mix-ups there's no policy and procedure requiring specific a specific medication lineups on the cart themselves again this becomes a latent root because we're at a systemic level abnormal number of interruptions and distractions that day how can that be this is consistent with the understaffing claim earlier about why we take shortcuts we were understaffed that day because of the unusual number of interruptions and distractions that we had with the patient load that day and lastly we come over to normalization of deviance normalization of deviance comes out of the spaceship space shuttle Challenger investigation and what it focuses on is a gradual deterioration of our safety standards it means that when we're time-pressured and we take a shortcut and nothing bad happens that becomes our new norm so we've really lowered our standards and that when that continually happened it usually takes a catastrophe before we set back to zero so that's where the term normalization of deviance comes from how could that have evolved well the shortcuts evolved into prevailing practice again when we take these shortcuts and you know when management is overseeing these and when nothing bad happens we're still in good graces but when something bad happens is only when we're held accountable how could shortcuts evolved into prevailing practice inadequate training in this case proven not to be the case poor supervision in this case not the case for teamwork I think we have had poor teamwork the silo paradigm is normal practice in this particular location well why is the silo paradigm acceptable because management systems do not promote or support the teamwork will discuss the late root causes in detail later but we're trying to show how efficient systems that we have in place that are meant to help us make better decisions or really working counter productively for us in the real world so what we want to get rid of this silo paradigm and replace it with a teamwork type of paradigm general understanding on the unit adds to the lack of xiv teamwork okay and lastly we have the automatic reflex again where the perceived time pressure is a due to the general understand ER staffing in this case again it's an incorrect assumption that we make on a day to day basis because this is the acceptable practice so we just go with it this is business as usual as I mentioned earlier we talked about management oversight whenever there is a violation of a policy then we also have to look at the checks and balances in place and say should management have caught this as part of the checks and balances before there was any risk of harm to the patient so we also look for management system deficiencies in oversight as well as the existence of policies and procedures and things of that nature ok let's return back to our presentation now here is a synopsis if you will of a overview of our RCA findings in general no policy and procedures to handle discontinued medications in the court number 2 general understaffing on the unit number 3 the lack of adequate management oversight to observe these deficiencies and to do something about it before they got to the patient incorrect assumption common practice this is the common reflex that we were talking about we get into the rut of just following what people normally do and lastly management systems do not promote or support teamwork with that I'm going to turn it over to Beth again thanks Bob before I add a little bit more detail to the findings in the root cause analysis let's take a closer look at what a typical medication cart looks like you can see in the upper left that there is a lock for the cart on the right there is a narcotic straw and lock with other drugs for patient medications some of which are stock medications and possibly other tools or bandage supplies that a nurse might use throughout the day DRN had but they had the keys to both locks and would be expected to keep them locked unless removing medications there you can see a closer view of what the regular prescription medication punchcards look like in their draw with those tabs that are sticking up separate the patient per patient medications and then on the right side of the screen you see that narcotic straw and the rows of punch cards that would be a different one for each patient the first finding the there was no policy or procedure to handle the discontinued medications in the cart you can see how similar these punch cards would look and then a little picture of the quantity aqua nozzle p.m. and Laura the RCA finding that there was general understaffing on the unit is related to the increase in interruptions and distractions and along with it the increase in potential for errors some examples of the increased distractions or interruptions that would occur in an understaffed situation would be the residents would be waiting for care longer and therefore they'd have to use their call bills to signal a request for help more frequently if the residents have to wait longer for care or to get out of bed or out of their chair they may attempt to do that without waiting for assistance that would set off potentially a chair alarm or a bed alarm the licensed nurse assistance would be asking the registered nurse for more help when a quick extra pair of hands was required just to move somebody booth somebody up in bed or to help with a transfer the residents actually may even resort to calling the nurse's station on the phone to get the attention of the nurse and of course it would be longer wait times to answer all of the call bells and phone calls and alarm which would add to the duration of noise on the unit the step-by-step protocol for administering controlled substances as with other medications requires concentration checking the time the dose the rid of the drug in the medication administration record unlocking and locking across the narcotic straw to make sure that the right patient receives the right drug at the right time and that the documentation is accurate on the medication administration record as well as the Controlled Substances book are all part of this process interrupting a sequence of steps would require the nurse to start over and possibly multiple times okay thank you Beth I wanted to go over the lack of adequate management oversight because what I wanted to be able to do is just highlight awareness to the fact that yes people will tend to not follow procedures for various reasons but our checks and balances as part of a system should be that our management oversight should be able to detect when these violations or deviations occur so that we can prevent it from actually reaching the effects of it reaching the patient so whenever you're conducting a root cause analysis and you cite that someone wasn't doing something or something somebody should have been doing something that they weren't then we should also look at the management oversight side and say you know do we have a system in place that is a it provides such a checks and balance and if we do how come on the management oversight side we didn't pick it up so from that standpoint I want to be able to highlight that there's a shared contribution to these types of failures by the fact of the people that actually make the violation or deviation and those that should have detected it thank you Bob the fourth finding that the RCA analysis came up with was that there was an incorrect assumption made and this incorrect assumption made was that the arms were administering medications according to protocol when in fact as you mentioned earlier they had developed several common practices these practices were not talked about openly and yet they were common among all of the nursing staff some examples of this where that they the nurses would take a medication out of the punch card before comparing it to the medication administration record leaving it in the drawer just pulling it up and punching out the medication they wouldn't another example would be that they wouldn't start over with medication administration step following an interruption an interruption or interruptions so they might not place the punch card on the med cart directly next to the medication administration page which would allow them to look at both the doctor's order on the medication administration record and the actual pill punch card pills that they had in their hand they just skip that step they might rely on memory and they may choose to document what they did later on in the shift rather than at the time of administering the medication and the last finding was that the root cause analysis revealed that the existing management systems tended to promote a silo mentality and discourage teamwork you can see how those could happen in conjunction with the short staffing that people were tending to try to get their own work done rather than the bigger picture of the unit and getting everything done together such systems need to be reviewed from the context of a bigger picture to see how individuals departments and systems can be interrelated for synergistic effect so ultimately this logic tree and the RCA findings lead us to four recommendations that would prevent future medication errors first developed an implemented policy and procedure for removing discontinued medications from the medication cart include a process for tracking mechanisms and management oversight for Chuck imbalances second review current staffing of our ends and LMAs on this unit address deficits and develop backup plans to replace staff who call in sick or who are utilized in another part of the facilities very provide complex management training for our ms and incorporate opportunities to develop therefore practice the skills this would include a feedback loop on how could you do it better and what do you need to do it better so that next time around the conflict management outcome would be more successful lastly of course review the proper drug administration protocol with nurse and monitor the application of the protocol so in summary everyone pulling together for our patients and for our staff so that we are providing health care and a safer cost-effective and compassionate way thanks Bob Thank You Beth this concludes the RCA case study from our lessons learned series we would like to thank you for your time and your interest in this particular case if you would like more information from the speakers please feel free to contact best at the information below for myself bob latino with my information below we thank you for your time and interest and your partnership with us in patient safety thank you and good luck

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