A series of medication errors occurred on a care area and are believed

QUESTION

A series of medication errors occurred on a care area and are believed to be caused by the redesign of the unit dose delivery system.

Who should the nurse manager expect to participate when conducting a root cause analysis of these occurrences? (Select all that apply.)
1. Nurse manager
2. Pharmacy director
3. Nurses who made the medication errors
4. Person who delivered the unit dose device
5. Pharmacist responsible for filling the unit dose device

ANSWER:

Correct Answer: 1, 2, 3, 5

Root cause analysis is a structured method used to analyze serious adverse events, with focus on identifying what, how, and why an event occurred in order to understand and eliminate the root causes and prevent recurrence. Root cause analysis uses a multidisciplinary team approach to reconstruct the events leading up to the occurrence with particular focus on underlying problematic system factors. It usually involves medical record review and staff interviews. The nurse manager, pharmacy director, nurses who made the medication errors, and the pharmacist who filled the unit dose device should be in attendance. The individual who delivered the unit dose device to the care area does not need to participate with the root cause analysis.