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Home/Law/The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could “snowball” into patient injury?

The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could “snowball” into patient injury?

I think that I would identify the given dismissal of the “five rights” as soon as I observed that the connectivity issue was a problem. The “five rights” are comprised of “the right patient, the right drug, the right dose, the right route, and the right time.”

In other words, the lack of wireless connection in the furthest rooms and the subsequent relocation of the patient labels near the computer would signal me that the “five rights” are not being adhered to, which would result in an immediate reporting of the issue to the superiors.

It is stated that “managers must provide the required personal, professional and legal support for nurses to encourage them to effectively report errors, discover the root cause of errors and take measures to prevent them.” Thus, managers would have to fix this issue since it is their responsibility to provide structured work conditions.

The one issue “snowballed” into a patient injury because of the work culture at the facility. It is of paramount importance for the specialists to report any non-adherence to the fundamental protocols, but the case reveals that there were no elements of Just Culture, which promotes error reporting.

One should not fully attribute the blame towards the nursing professionals only since it is likely that such negligence in reporting the connectivity problem is partly or even fully due to poor management. Managers might have been detached from the nurses or hostile to any form of complaint, which discouraged the nursing specialists from reporting the issue, and thus, they were forced to create workarounds, such as keeping patient labels in bulk at one location.

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Academic.Tips. (2023) 'The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury'. 12 March.

Reference

Academic.Tips. (2023, March 12). The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury? https://academic.tips/question/the-rca-determined-that-the-facility-which-was-relatively-new-lacked-sufficient-wireless-coverage-at-the-end-of-each-unit-this-created-a-connectivity-issue-with-the-barcode-scanners-used-for-medica/

References

Academic.Tips. 2023. "The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury?" March 12, 2023. https://academic.tips/question/the-rca-determined-that-the-facility-which-was-relatively-new-lacked-sufficient-wireless-coverage-at-the-end-of-each-unit-this-created-a-connectivity-issue-with-the-barcode-scanners-used-for-medica/.

1. Academic.Tips. "The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury?" March 12, 2023. https://academic.tips/question/the-rca-determined-that-the-facility-which-was-relatively-new-lacked-sufficient-wireless-coverage-at-the-end-of-each-unit-this-created-a-connectivity-issue-with-the-barcode-scanners-used-for-medica/.


Bibliography


Academic.Tips. "The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury?" March 12, 2023. https://academic.tips/question/the-rca-determined-that-the-facility-which-was-relatively-new-lacked-sufficient-wireless-coverage-at-the-end-of-each-unit-this-created-a-connectivity-issue-with-the-barcode-scanners-used-for-medica/.

Work Cited

"The RCA determined that the facility, which was relatively new, lacked sufficient wireless coverage at the end of each unit. This created a connectivity issue with the barcode scanners used for medication administration. Following a workaround that developed over time, clinical staff would print additional patient labels, which could be scanned at the medication administration location away from the patient (not at the bedside). Subsequently, the provider would walk to the room and provide the medications – bypassing the barcode safety net. This workaround process devolved over time such that medication was being dispensed for multiple patients (batch processing) and then, with multiple medications in hand or on the provider, delivered to patients, room by room. In this real example, the nurse pulled the wrong medication from their pocket and did not confirm the 5 Right before administering. The patient had an adverse event that brought this all to light. There was no record of any staff reporting the wireless issues – even though it was commonly known amongst staff and middle management. Knowing the actual root cause, what are your thoughts on how you would respond and how one issue could "snowball" into patient injury?" Academic.Tips, 12 Mar. 2023, academic.tips/question/the-rca-determined-that-the-facility-which-was-relatively-new-lacked-sufficient-wireless-coverage-at-the-end-of-each-unit-this-created-a-connectivity-issue-with-the-barcode-scanners-used-for-medica/.

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