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NURS FPX4020 Assignment2 Attempt1.docx NURS-FPX 4020 Root-Cause Analysis and Safety Im

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NURS FPX4020 Assignment2 Attempt1.docx NURS-FPX 4020 Root-Cause Analysis and Safety Improvement Plan NURS-FPX4020 Capella University Root-Cause Analysis Medication administration is a high-ris... k nursing procedure. There is a chance for medication administration errors throughout every medication pass. At a small hospital outside of Philadelphia, failure to document and communicate a proper shift hand-off led to the error of double administering high dose warfarin. Both the dayshift and nightshift nurse were held accountable for this medication administration error and have influenced new measures improving both medication administration and patient hand-off. Analysis of the Root Cause A new floor nurse was administering a high dose of warfarin, an anticoagulant to a patient for treatment of a deep vein thrombus. This nurse was balancing the care of five other patients, as well. In haste, the nurse administered the medication, without scanning it into the barcoded medication administration program, and continued to the next patient. When the night shift nurse started her medication pass, she noted that the patients 5pm dose of warfarin was still outstanding, and she administered it late with the 9pm medications. When giving report in the morning, the dayshift nurse who failed to scan the medication was back and the night shift nurse relayed that she did administer the warfarin dose that she thought was missed. The dayshift nurse quickly realized her mistake and the attending physician and pharmacy were notifi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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