A nurse is conducting a root cause analysis of a medication error that occurred in their unit. Which of the following steps should the nurse take first?

Identify all the factors that contributed to the error

Implement corrective actions to prevent the recurrence of the error

Communicate the findings and recommendations to the staff and stakeholders

Gather information and evidence about the error

Answer and Explanation

The Correct Answer is D

The first step in a root cause analysis is to collect data and facts about what happened, when, where, how, and why. This includes interviewing the staff involved, reviewing medical records, policies, procedures, and protocols, and examining equipment and environmental factors. Gathering information and evidence helps to establish a timeline and a causal chain of events that led to the error.

Incorrect choices:

a) Identify all the factors that contributed to the error: This is a later step in a root cause analysis, after gathering information and evidence. Identifying contributing factors helps to determine the underlying causes and system failures that allowed the error to occur.

b) Implement corrective actions to prevent recurrence of the error: This is another later step in a root cause analysis, after identifying contributing factors. Implementing corrective actions involves developing and testing solutions that address the root causes and improve patient safety.

c) Communicate the findings and recommendations to the staff and stakeholders: This is the final step in a root cause analysis, after implementing corrective actions. Communicating the findings and recommendations involves sharing lessons learned, best practices, and feedback with those who are affected by or involved in preventing similar errors.

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Correct Answer is D

Explanation

This is the safest action to take when there is a discrepancy between the barcode and the label of a medication. It prevents administering the wrong medication to a client, which could cause harm or adverse effects. It also alerts the pharmacy of a possible error in dispensing or labelling the medication.

Incorrect choices:

a) Administer the medication as prescribed and document the discrepancy: This is not a safe action to take when there is a discrepancy between the barcode and the label of a medication. It could result in administering the wrong medication to a client, which could cause harm or adverse effects. It also does not address the source of the error or prevent its recurrence.

b) Check the medication label and the prescription order again: This is not a sufficient action to take when there is a discrepancy between the barcode and the label of a medication. It could lead to confirmation bias, where the nurse overlooks or ignores the discrepancy and assumes that the medication is correct. It also does not address the source of the error or prevent its recurrence.

c) Contact the pharmacist and verify the medication: This is not an appropriate action to take when there is a discrepancy between the barcode and the label of a medication. It could delay the administration of the medication or create confusion about which medication is correct. It also does not address the source of the error or prevent its recurrence.

A. "I should tell the nurse if I notice any unusual symptoms after taking my medication." B. "I should check the label of the medication before I take it to make sure it is mine." C. "I should not worry about minor errors because they are unlikely to cause any harm." D. "I should ask questions if I am not sure about the purpose or side effects of a medication."

Correct Answer is C

Explanation

This statement reflects a lack of understanding of the potential consequences of medication errors. Even minor errors can lead to adverse events, complications, or increased length of stay. The client should be aware of the risks and benefits of their medication and report any errors or concerns to the nurse.

Incorrect choices:

a) "I should tell the nurse if I notice any unusual symptoms after taking my medication.": This statement shows that the client understands the importance of monitoring for adverse reactions and communicating with the nurse.

b) "I should check the label of the medication before I take it to make sure it is mine.": This statement shows that the client is taking an active role in preventing medication errors by verifying their identity and medication.

d) "I should ask questions if I am not sure about the purpose or side effects of a medication.": This statement shows that the client is seeking information and clarification about their medication, which can enhance their safety and adherence.

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A nurse is conducting a root cause analysis of a medication error that occurred in their unit. Which of the following steps should the nurse take first?

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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A nurse is conducting a root cause analysis of a medication error that occurred in their unit. Which of the following steps should the nurse take first?