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PS-009 Medication error: feedback concerning the death of a nursing home resident
  1. V Grenouilleau,
  2. L Faraggi
  1. CSMR de Podensac, Pharmacie, Podensac, France


Background During the morning medicines round, an 82-year-old resident received another resident’s treatment by mistake. The nurse’s aide realised her mistake and warned the charge nurse upon her arrival. The doctor was informed and the appropriate surveillance was implemented. That same evening, following a significant decrease in alertness and low blood pressure, the resident was admitted to intensive care. The following morning, the resident was declared dead. A root cause analysis was performed with the support of the “Regional Platform of Support for the Management of Adverse Events”.

Purpose To demonstrate the benefits of a root cause analysis in the management of serious adverse events.

Material and methods The root cause analysis was performed using the Orion method.

This method includes the following steps: i) data collection, ii) chronology of events, iii) identification of gaps, iv) identification of contributing and influencing factors, v) development of action plan, vi) drafting analytical report.

Results The root cause analysis was performed by medical and paramedical professionals as well as management representatives.

Corrective actions were proposed: i) ensure “double-check” patient’s identity by writing a drug distribution procedure and training all staff members, ii) raise team awareness by sharing this feedback (posters, scenario analysis), iii) identify drug distribution boxes with a photo ID, iv) expand the workspace, v) improve the working conditions of the agents (new organisation, risk study).

Conclusion As a result of the root cause analysis, corrective actions involving all concerned agents have been implemented.

These actions not only helped to make drug administration safer but also to educate the teams, set up more secured work environments and to develop identity monitoring.

Systematising the practice of root cause analysis is required in nursing homes as part of the continuous improvement of quality and the safety of patient care.

The pharmacist plays an important role in this new risk management.

References and/or acknowledgements No conflict of interest.

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