Analysis of Medication Administration Error in the Emergency Department (ED) using Fault Tree Analysis (FTA)

Many medical errors exist in the current healthcare system involving the emergency department (ED). Often the situations in the ED are unique to the ED because of its fast-paced and high-stress nature. For example, medications may be urgently needed in the ED, requiring immediate retrieval from the automated dispensing cabinet or prescription of medication on the spot (Pennsylvania Patient Safety Authority, 2011). Of the medical errors, medication error presents the most prominent and common error. According to Pennsylvania Patient Safety Authority (2011), prescription errors (53.9%) account for the majority of medication errors observed in the ED, followed by administration error (34.8%), transcription error (10.7%), and dispensing error (0.6%). This case analysis will focus on analyzing nurses medication administration error in the emergency department using a fault tree analysis (FTA). Using an FTA, the root causes of medication error in the ED can be analyzed and distilled into direct human actions and organization structure flaws that can then be addressed individually. 

System Components

The ED, as a complex, dynamic socio-technical system, involves multiple components. The system includes physicians who prescribe the medications, nurses who administer the medications, and patients, who may have underlying complications that contribute to the uncertainty and complexity of the medication system in the ED. Pharmacists act as checkpoints and safety stops for physicians by reviewing the medications prescribed or prescribing medications themselves. Manufacturers also act as a part of the system as they are responsible for the naming and packaging of the medications.

Commonly observed failures 

The process of medication administration includes the following steps from a top-down process view: manufacturer producing the medications, physicians choosing the medication, the nurses obtaining the medications from the auto dispensing cabinet or retrieving from the pharmacist, and the nurses administering the medication (University of Iowa Health Care, 2019). Each step can introduce opportunities and present as underlying causes of administration of incorrect name or dose of medication in the ED. Some of the errors that nurses might make can also be a direct result of other team members’ mistakes. This includes prescription mistakes made by the physicians or pharmacists even though the nurses retrieved the correct dosage and medication type or organization protocol design error for not including safety checks when administering medications with significant side effects. Pharmaceutical companies contribute to medication errors as research shows that similar looking and sounding medications can lead to medical errors both for professionals and patients (da Silva & Krishnamurthy, 2016).

FTA discussion and conclusion

The problem discussed in this case analysis starts with errors in nurses administering medications. The error can be attributed to a collection of active errors such as obtaining the wrong medications due to similar medication names or passive errors where nurses fail to check or implement a safety stop before administration. Active errors are mainly attributed to a lack of situational awareness (SA) caused by stress, fatigue, and a lack of knowledge, which is caused by a failure to anticipate, inadequate training, and insufficient information. Cognitive deficiencies are the main root causes leading to nurses administering the wrong medications. 

The right side of the branch analyzes the causes that nurses failed to correct the mistake before administering the medication. The main attributions are organizational protocol and policy deficits. A shortage of staff can also cause distraction, which is also caused by cognitive overload and poor team situational awareness attributed by a lack of communication and defined roles. (Bullemer & Reising, 2013; di Simone et al., 2018). A finding towards the bottom of the diagram, as a basic event, is the failure to anticipate upcoming events and poor management, affecting the staff structure and team SA, which then affects performance negatively (Fore & Sculli, 2013). Also related to one of another basic, inevitable event is the nature of ED, being a chaotic and primarily unpredictable system (di Simone et al., 2018).

The FTA presents an organized way to define the root causes of an error and often find overlapping themes between the errors, making the system correction process more productive and effective. For example, inadequate training and a lack of protocol can both affect the cognitive aspects and organizational structure of the system. By providing additional appropriate training and additional protocols, the ED will benefit from enhancing checkpoint implementations and increasing the nurses’ knowledge (di Simone et al., 2018). Because the FTA defines the entire cascade of events, the possibility of straightforward preventions is also noted as the FTA is performed. For example, on the left side of the branch, the auto-dispenser dispensing the incorrect medication presents as a simpler branch, caused by a stocking error and the nurse failing to correct it. Since automated dispensing cabinets provide positive results in lowering medication error (Fanning et al., 2016), correcting stocking errors, increasing staff sources can eliminate one cause of nurses obtaining the wrong medication early in the cascade. 

From the FTA, most of the primary causes are analyzed to be on the right side of the branch, which indicates the majority of organizational design flaws, including short staffing, underdeveloped protocols, and ill-defined roles and goals. They are the current flaws in the system and can be corrected as time goes with effort. On the other hand, there are many undeveloped events on the left side of the branch, indicating that the events involve other components, in this case, physicians, pharmacists, and pharmaceuticals. Nurses can only catch or prevent errors made by others to a certain degree. This is one inevitable nature of complex systems. Components within the same system are interrelated and have cascading effects, yet they are unpredictable and uncontrollable by other components, such as represented by nurses. For this reason, eliminating all hazards in a complex system is not possible, especially when the system takes place in an ED, which has added levels of dynamics and chaos. Therefore, based on the FTA, to improve the accuracy of medication administration, one should focus on improving the organizational structure including increasing staff to both lower cognitive overload, especially in ED, and increase safety net for double checking in the administration process as in blood transfusion protocols.