Reference no: EM132301918

A hospital did a root cause analysis (RCA) in order to find out what was causing so many medication errors. They found the following four causes: 1) two drugs have similar names; 2) Nurse fatigue; 3) communication breakdown; 4) Incorrect conversion of units. The risk of a communication breakdown is 8%; each of the other causes has a 5% chance of happening. If 3 out of 4 events happen (or 4 out of 4), this will result in a “medication error!” If two events happen, this is a “near miss.” If one event happens this is a “fix problem.” If “zero” events happen this is a “Looks good!” For each process, use random numbers to simulate whether a condition exists that may cause an error. (To recalculate, use the “F9” key.) The color green should be used to indicate “no problem.” The color “red” indicates there is a problem that MAY lead to a medication error. Construct a table of random numbers to “simulate” these latent conditions. Construct a “dashboard” that is a visual representation of the process on a spreadsheet. Simulate 50,000 medication orders – How many errors occurred? Try to make the spreadsheet as clear and intuitive as possible.

For every medication error, there is a 5 percent chance that this will lead to the patient’s death. [Example: giving an adult chemotherapy dose to an infant.] How many patient deaths will be caused by this system? How can this “dashboard” be used to reduce patient deaths?