Background Patient safety is a serious global public health issue. Causal analysis with a systematic and participatory approach is a useful tool for improving safety.
Purpose To perform a root cause analysis (RCA) in a medication error in order to identify improvement opportunities, to propose actions aimed to increase patient safety and to promote a collaborative approach in the health team.
Materials and Methods Retrospective study by the Patient Safety Team using RCA to investigate the cause of a medication error that happened in the paediatric unit in a tertiary level hospital, Spain. It included the following steps: identification and selection of the error, data collection and description of the event, construction of facts map, analysis of contributing factors and study of barriers that may prevent damage and finally, developing solutions and an action plan.
Results An administration error in a paediatric patient was selected. The patient received a single dose of antibiotic instead of a dose every 24 hours. RCA permitted the identification of human and patient factors as well as latent system failures associated with organisational factors and factors related to equipment, procedures, working conditions, education and training. Electronic prescribing and an individualised dispensing system failed as the main barriers.
The action plan proposed by the interdisciplinary team included: modification of the individualised dispensing system for the paediatric unit, improved electronic prescribing software, systematic visitor pass medical-nurse, and review of returns in the individualised dispensing system to detect errors.
Conclusions The analysis of a medication error by RCA identified the factors that caused the event and was a learning opportunity for the health team. Its use permitted a patient safety improvement through the identification and correction of latent system failures.
No conflict of interest.
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