Quality Risk Management plan

Prompt – DUE Saturday 9/11 – APA format – 10 pages – 4 references minimum Quality Risk Management Plan For your final Portfolio Project, you will write a paper based on the following case study scenario: Interim Bulletin: Wrong Route Administration of an Oral Drug into a Vein Your goal is to address the areas of risk and quality improvement related to healthcare/medical errors, as well as to safeguard future patients from having their safety compromised like what occurred in this case study. Instructions: Your quality and risk management plan must include: A root-cause analysis; At least two recommendations for improvement; Identification of all employees’ roles in your analysis; An assessment of what the facility can do going forward to create a culture of quality and safety; Quality, risk, and performance improvement diagrams and charts (e.g., a fishbone or other visual forms of root cause analysis, Pareto chart, tables, etc.) to support your analysis; and A commentary that relates the case broadly to what has been covered throughout the course and describes the roles played by quality and regulation to prevent occurrences such as the case described. Brief Summary- A nine year old pediatric patient was administered an oral liquid sedative medication (Midaolam) by vein before an elective surgery of a renal biopsy. The medication was prescribed as intravenous by the doctor. The nurse prepared the medication in the treatment room, but she assumed it was for oral administration and prepared the drug with the specific oral syringe with a purple top. Both the nurse and the doctor checked the medication and did not recognize the mistake. The nurse left the room and a different doctor entered the side room (where the operation was to be preformed) and administered the oral drug intravenously. The oral syringe would not connect correctly to the cannula and the contents were decanted to the clear syringe which was designed to connect to the cannula. The doctor noted that the syringe was difficult to push. Medicine then leaked on the doctor’s hand who then realized that there was a serious problem and ceased the procedure. The child was monitored for 24 hours and then underwent the procedure with general anesthesia the next day. Root-Cause Analyst Root-Cause “Root-cause analyism is an analytical process and calls for rigourous thinking about interlated cause and effect relationships within a system that has failed” (Okes, 2008). In regards to this case study, the problem is defined as an oral medication being dispensed intervenously, thus putting the patient’s health in jeapordy. Mistakes regarding intravenous medication are the most common medication mistake (Guiliano, 2018). The causes of this case study can be debated, but it there seems to be a lack of communication between the prescribing doctor, the nurse who chose the oral medication, and then the doctor who administered the drug. A key word in the case study is that the nurse “assumed” that the medication was for oral administration. However, both the nurse and the prescribing doctor admitted to double checking the medication prior to administering. Increased communication and a stronger system in place to monitor medication administration could have made a big difference in this case. The supporting data shows that there are many steps to medical administration where the problem can begin — from prescribing, transcribing, dispensing, administering, and even though in this case study the administration was ceased after realizing the error, monitoring the drug. Root-cause analyst infograph Inforgraph (Okes, 2008) Recommendations for Improvement Recommendations for Improvement Algorithms Algorithims This case study is not a one-time accident. Medical Administration Errors are the most common type of medication error (Wondmieneh et al., 2020). Therefore, I would find it prudent for our hospital to utilize another layer of protection over our patients. It is common in risk management to set up preventative emergency measures to ensure the safety of the staff and patients (Labelle

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