This essay focuses on Multifactorial Medication Mishap.Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).
Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).
Complete the Root Cause Analysis Worksheet to analyze the case.
Multifactorial Medication Mishap Case Study:
The Case A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge.
At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name.
In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product and ordered a 5-mg dose. All medication orders at the hospital had to be verified by a pharmacist.
Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she was more used to giving, and then left for her break.
A covering nurse checks on the patient and found him unconscious — a code blue was call. The naloxone (an agent that reverses the effect of opioids), and he respond well. He was transfer to the intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the effect of the oxycodone. By the following morning, the patient had return to his baseline with no apparent adverse effects.
Firstly, Explain why a root cause analysis was appropriate for this situation.
Secondly, Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.
Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.
Submit your worksheet and summary.
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