Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Root cause analysis (RCA) systematically and methodologically investigates an occurrence to identify the reason for a system failure that might not be apparent initially after the incident. System and personal failures can lead to patient safety risks, including medication errors (Center for Drug Evaluation & Research, 2019).

A root cause analysis was conducted to investigate an incident in the surgical postoperative unit that involved a morphine overdose. The purpose of this paper is to describe this incident, conduct a root cause analysis, and develop a safety improvement plan to prevent these occurrences in the future in the organization.

Root-Cause Analysis of Falls of Medication Errors

Charlie is a 20-year-old white female who had an emergency appendectomy three days ago due to acute appendicitis. Today, he still complains of severe pain at the incision site and the abdomen. During the review in the afternoon, his surgeon prescribed oral morphine 10mg Stat for his pain and documented that prescription in writing in the patient’s physical records.

The same evening, four other patients were admitted from the operating room and post-anesthesia care unit (PACU). RN, the day shift nurse in charge of the room, delegated the administration of morphine to a student nurse because she was attending to the new admissions. Charlie had been on IV painkillers in the first two days but showed suboptimal pain control. The student nurse picked IV morphine rarely used in the unit, and administered 10ml instead of the 10mgs prescribed by the surgeon.

The surgeon, who happened to be the head of the department of surgery, and the nurse manager in charge of the department agreed that a root cause analysis of the issue be done because there had been prior near misses in the last in the same department.

The RN discovered the issue on her hourly reviews when she noted that Charlie was becoming drowsy and confused and had vomited twice about half an hour after drug administration. The event necessitated the use of naloxone use to reverse the side effects of morphine overdose. A multidisciplinary care team was formed that monitored Charlie’s postoperative healing and recovery.

Analysis of Root Causes

The most common practice factors involved in medication errors include training, engagement, motivation, and work organization system. Interruptions commonly lead to medication errors by breaching the work organization system, thus increasing the risk of making medication errors of omission due to a break in concentrations (Schroers et al., 2022).

Possible outcomes are wrong medication, wrong dose, or wrong route in medication administration. Transitions in care provide a high risk of making medication errors. During this time, there are high chances of a break in the continuity of care, which can involve the patient medication lists.

Human factors contributing to the medication error included understaffing leading to nursing overload and delegation. The use of untrained personnel, the nurse student, to perform medication administration could contribute to the error due to inadequate competencies (Schroers et al., 2020).

Failure to double-check the prescription before medication administration led to the wrong medication and the wrong route of administration. A high patient-to-nurse ratio n could also contribute to medication errors from fatigue and burnout.

Documentation is a crucial method for interprofessional and intra-professional communication. Using manual documentation to provide prescriptions can cause medication errors due to illegible writing and confusion from lookalike sound-alike (LASA) drugs (Wondmieneh et al., 2020).

Communication is also important in medication reconciliation and double-checking the medication before administration. This could reduce the risk of medication errors in this case. Current methods of documentation utilize health technology to improve accuracy, efficiencies, and effectiveness in communication.

The nurse practice environment could also play a part in a medication error. Environmental factors such as shift and nurse staffing capacities can contribute to medication safety (Savva et al., 2022). Additional work is created for nurses in understaffed environments. This contributes to fatigue and exhaustion, which can cause medication errors.

The nurse, therefore, works to complete more tasks in a shorter time and may omit some tasks to save time. A surgical environment is a busy environment for a nurse, and completing all designated tasks can require additional speed. In Charlie’s case, poor documentation, understaffing, lack of communication, and poor care transition were the root causes of the medication error.

Application of Evidence-Based Strategies

Root causes of medication errors can be classified as personal and contextual factors. Personal factors are related to the clinician factors, while contextual factors are due to circumstances under which these errors occur. About 8%–25% of medication errors occur due to administration. About 48% – 53% of these errors can occur due to intravenous drug administrations (MacDowell et al., 2021).

In an ideal setting, medication administration should follow a sequential and controlled procedure. Practice, environmental, equipment, and communication factors contribute to medication errors related to medication administration. Shift reporting, staffing, nurse fatigue, poor communication, and interruption are the most commonly reported cause of medication safety risks.

Various strategies have been implemented in advanced settings to prevent medication errors. These strategies include but are not limited to the use of technology, medication reconciliation, interdisciplinary team collaboration, communication, and coordination (Agency for Healthcare Research and Quality, 2018).

The use of technology reduces medication errors by about 50%. Some of the technologies that have been employed to reduce, prevent and reduce medication errors are clinical decision support systems (CDSS), computerized physician order entry (CPOE), and electronic health records (EHRs). These technologies can be synchronized in one technology system for the organization. Most importantly, clinicians must be trained on how to use these medications to enhance usability and uptake to make the process or error reduction realistic.

Medication reconciliation is an evidence-based strategy that has been documented and practiced for a long time now. However, when and where to practice medication reconciliation varies from organization to organization protocols. Performing medication reconciliation at every point of care transition makes this strategy more potent and effective.

More than 70% of medication errors are reduced when medication reconciliation is done at admission, shifting, patient transfer, and discharge (Rosenthal & Burchum, 2020). This strategy should not only be practiced by nurses but also by other clinicians.

Interdisciplinary collaboration, communication, and coordination are strategies that make other strategies effective. Without these interdisciplinary efforts, medication reconciliation and technology use can be challenging to achieve. Nurses and nurse leaders play important roles in ensuring interdisciplinary approaches through effective and timely communication and collaboration.

The process of nursing care coordination sums up this strategy. Collecting and disseminating pertinent patient information to all stakeholders can improve patient safety. This process requires assistance from technology and nursing education to make it efficient. Coordinating with the patient is also crucial so that they know what they are taking, why they are taking it, and what it can do when not taken properly. This is achieved through patient education to improve compliance and thus adherence.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The National Coordinating Council for Medication Error Reporting and Prevention definition of medication errors emphasizes their preventability (Tariq et al., 2022). Various quality improvement plans can be implemented to prevent medication errors in the aforementioned scenario.

My improvement plan for this seating will include three actions: incorporate technology in prescription, conduct bedside shift reporting, and conduct mandatory medication reconciliation at every point of care transition. As aforementioned, transitions in patient care provide the most chances for medication errors. Therefore, they can also provide the best opportunity for clinicians to prevent these errors.

Implementing CPOEs and CDSS will assist the clinician with prescription and decision-making by providing alerts and warning for potential medication safety risks. These technologies also provide clinicians with platforms for communication and collaboration.

They will make the process of interdisciplinary collaboration and coordination efficient. The last part of the plan is to implement bedside shift reporting to provide an opportunity for medication reconciliation. Handing over at the patient’s bedside will enhance care collaboration that will also be patient-centered, thus lowering the risk for patient safety concerns.

This plan aims are preventing future medication errors and empower interdisciplinary participation in the unit through the three strategies. Expected outcomes include reduced patient medication adverse events, improved patient satisfaction, reduced patient stay, and improved patient-centeredness in care. Implementation of the plan will adopt a PDSA cycle process for projects. Completion of the first cycle can take about three months, and regular monitoring and evaluations will be conducted to ensure project effectiveness.

Existing Organizational Resources

Implementation of the above quality and safety improvement plan will require human and technological resources. While it aims at solving the human shortage at the same time, this plan will require the human skills to actualize the technological plans.

A health information system will be the first essential resource for plan implementation. Human resources that would be required include nurse informaticists and healthcare system technologists. An electronic health information system is required to support various technologies that would be implemented to actualize the project plans. Existing resources in the organization include human resources and electronic health records.


The medication safety issue involved a young adult, a postoperative patient, who received a morphine overdose jeopardizing his safety. Root cause analysis revealed various root causes of medication safety: poor communication, understaffing, and poor care transitioning. Evidence-based literature has documented the above causes, either personal or contextual. Medication administration has been a significant source of medication errors.

Strategies to reduce these errors have included medication reconciliation, health technology use, and interdisciplinary teams. Communication, collaboration, and coordination have been effective in patient safety risk reduction. The quality improvement plan to address the issue included implementation of CDSS, using CPOE, and implementing bedside shift reporting. Human resources and electronic health records are vital resources that will be required to actualize this plan.


Agency for Healthcare Research and Quality. (2018, August). Care Coordination.

Center for Drug Evaluation, & Research. (2019, August 23). Working to Reduce Medication Errors. U.S. Food and Drug Administration.

MacDowell, P., Cabri, A., & Davis, M. (2021). Medication Administration Errors. Intensive Care Medicine.

Rosenthal, L., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.

Savva, G., Papastavrou, E., Charalambous, A., Vryonides, S., & Merkouris, A. (2022). Exploring nurses’ perceptions of medication error risk factors: Findings from a sequential qualitative study. Global Qualitative Nursing Research9, 23333936221094856.

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. Joint Commission Journal on Quality and Patient Safety47(1), 38–53.

Schroers, G., Ross, J. G., & Moriarty, H. (2022). Medication administration errors made among undergraduate nursing students: A need for change in teaching methods. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing42, 26–33.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and prevention. In StatPearls [Internet]. StatPearls Publishing.

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1), 4.

Root-Cause Analysis and Safety Improvement Plan Instructions

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Analyze the elements of a successful quality improvement initiative.
    • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
    • Create a viable, evidence-based safety improvement plan for safe medication administration.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.


For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

  • The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
  • The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.


The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

  • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
  • Create a feasible, evidence-based safety improvement plan for safe medication administration.
  • Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

Additional Requirements

  • Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
  • Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

APA formatting: Format references and citations according to current APA style.