Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini-Root Cause Analysis and Action

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Medication Error Analysis

Background:

• Full root cause analysis (RCA) is resource-intensive for sentinel events.
• A need exists for efficient methods to address less severe medication errors.
• Quality improvement projects can adapt RCA for broader application.

Purpose of the Study:

• To evaluate the effectiveness of a mini root cause analysis (mini-RCA²) process for medication errors causing harm but not sentinel events.
• To determine the impact of mini-RCA² on the recurrence of similar medication errors.
• To estimate the time and labor costs associated with the mini-RCA² intervention.

Main Methods:

• A mini root cause analysis (mini-RCA²) process was implemented for medication errors causing harm (excluding sentinel events).
• The incidence of similar medication errors was compared before and after the mini-RCA² implementation.
• Data was collected from a safety reporting system, and costs were estimated.

Main Results:

• Seven medication errors were investigated, identifying 39 system failures and leading to 42 recommendations (22 implemented).
• Recurrence of similar harm events reduced from 7 (0.11%) to 0 (p=0.016), with full implementation yielding a reduction from 9 (0.21%) to 0 (p=0.007).
• The intervention required 251 hours and cost SAR 34,181 (US $8256).

Conclusions:

• Mini-RCA² offers a structured, efficient process for managing and reducing medication errors.
• The intervention successfully decreased the recurrence of similar medication errors, enhancing patient safety.
• Despite resource investment, the benefits of mini-RCA² outweigh the costs for healthcare organizations.