NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan Sample

Healthcare institutions have a well-defined process for conducting a systematic analysis of problems. The root-cause analysis is one of the most commonly used tools in this process. Root-cause analysis, as defined by Singh et al. (2021), refers to tools, approaches, and techniques used to identify the source of a problem. The root-cause analysis allows healthcare institutions to optimize care and design interventions to reduce negative outcomes in care. A root-cause analysis established to uncover the causes of medication prescription errors (MPEs), as discussed further below, is an example in health. In the discussion, a well-executed safety improvement plan to minimize adverse outcomes is also included.

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis

The identification of a multidisciplinary team to identify the problem is the first step in root cause analysis. In this case, the issue is MPEs, and the team consists of the prescriber, nurses, pharmacists, and, to a lesser extent, patients. The stratification of the causes into people, environment, methods, and systems or policies will be invaluable for the ease of identification of the causes of the problem. For example, under people, MPEs have been attributed to doctors’ poor penmanship. Because doctors are required to perform a variety of activities related to patient care, they are frequently pressed for time and, as a result, scribble down orders that are prone to errors in dosages, frequencies, or routes (Tariq et al., 2021).

Under environmental factors, distractions, as evidenced in practice and literature, are the most common cause and attribute to 75% of MPEs (Tariq et al., 2021). Distractions can come from fellow medics, patients, or anyone else in the ward’s vicinity. Patients crying out for help, moving along the corridors to the washrooms, colleagues consulting and asking questions, and subordinate staff cleaning the wards and corridors are all distractions that can divert the prescriber’s attention.

Under methods, abbreviations of medical terminologies are frequently used. However, drugs with similar generic names may have the same abbreviations, resulting in incorrect interpretation by pharmacists and the dispensing of incorrect medications (Tariq et al., 2021). Furthermore, apothecary or metric measures are commonly used during prescriptions. Incorrect use of these measures, such as not writing a zero before a decimal point (Insulin .5 IU/kg) instead of Insulin 0.5 IU/kg, can lead to medication errors. Concerning the system or policies, a suboptimal medication error reporting system can lead to MPE underreporting (Tariq et al., 2021). A non-functional Medication error reporting system is common in hospitals with poor collaboration of care providers, low motivation, and an increased work burden.

Evidence-Based Best Practices to address MPEs

Several evidence-based strategies for reducing the occurrence of MPEs have been proposed. In my institution, an emphasis has been placed on the medication error reporting system, and as a result, there is a welcoming environment in which open communication among care providers is encouraged. According to the literature, the majority of MPEs, such as incorrect dosage and infusion rate, are reported through an effective reporting system (Rodziewicz et al., 2021). Most institutions also encourage doctors to write orders or prescribe medications only at specific times, usually after the ward rounds, when there are fewer distractions and the likelihood of MPEs is lower.

Furthermore, educating prescribers on prudent prescribing is an evidence-based method of mitigating MPEs. This education can be provided through seminars, online webinars, and regular workshops, with one example being the antibiotic stewardship program, a coordinated initiative to promote the appropriate use of antimicrobials (Nimarko et al., 2020). Some organizations use prescription tools such as the STOPP (Screening Tool of Older Persons’ Prescriptions) and the START (Screening Tool to Alert to Right Treatment) to minimize MPEs. Moreover, MPEs can be greatly reduced by consulting before writing orders and double-checking dosages, frequencies, and routes.

Viable Evidence-Based Safety Improvement Plan for Safe Medication Administration

In healthcare, technology has been greatly leveraged to improve care outcomes. In an effort to reduce MPEs, electronic health records are being used to replace handwritten prescriptions. Wang et al. (2019) reported that using a computerized prescription tool eliminated MPEs caused by doctors’ poor penmanship. Furthermore, the computerized prescription tools automatically calculate dosages, standardize medication dosages, and sequence treatment days (Wang et al., 2019). The computerized prescription systems include embedded alert systems that detect any errors in the prescriptions

A computerized physician order entry system was successfully implemented in a Latin American hospital’s outpatient chemotherapy clinic. According to the findings of Valencia et al. (2018), the system successfully standardized 266 chemotherapy orders, and software that was linked to laboratory results allowed entry of important patient information such as anthropometric information for a fully automated dose calculation. As a result, such a system has been shown to be effective in lowering MPEs and improving patient safety.

Existing Organizational Resources that can enhance Patient Safety

As previously stated, my institution takes pride in having an effective medication error reporting system that improves detection of any MPEs. Having such an effective system in place is a top priority and a sufficient organizational resource that can improve patient safety. It is thus the responsibility of each health institution to motivate its employees, provide a safe work environment, and increase their satisfaction in order for them to be willing to promote the medication error reporting program. Furthermore, health institutions in the United States, for example, access the Pharmacopeia list of medications that are similar or have similar generic names and are likely to be confused (Tariq et al., 2021).

As a result, the United States Pharmacopeia is a resource that health institutions can use to prevent medication errors. Furthermore, the Institute of Safe Medication Practices maintains a list of all abbreviations that are frequently misinterpreted, as well as the names of high-risk medications (Tariq et al., 2021). Every time a doctor writes a prescription, he or she can refer to the lists to ensure that the correct orders and prescriptions are written.


Through safe evidence-based practices, MPEs are preventable actions. However, before implementing safe preventative measures, it is recommended that a root-cause analysis of the problem be performed. As can be seen, the causes of MPEs are numerous, with distractions being the most common. This therefore necessitates strategies. To reduce distractions while writing order. Technology has also provided a promising first step towards lowering MPEs. However, implementation has been difficult because most hospitals do not yet have an electronic medical record or any other systems or software that can incorporate computerized prescription. As technology advances, there is still hope that handwritten prescriptions will become obsolete in the near future.

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan References

Nimarko, K., Bandali, A., Bias, T. E., & Mindel, S. (2020). Impact of an antimicrobial stewardship team on reducing antiretroviral medication errors. The Annals of Pharmacotherapy, 54(8), 767–774.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. In StatPearls [Internet]. StatPearls Publishing.

Singh, G., Patel, R. H., & Boster, J. (2021). Root cause analysis and medical error prevention. In StatPearls [Internet]. StatPearls Publishing.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and prevention. In StatPearls [Internet]. StatPearls Publishing.

Valencia, F. S., Ruiz, R., Neciosup, S. P., Mas, L. A., Aliaga, K. M., Huaman, F., Ruiz, J., Vasquez, E., Llacctahuaman, N., Pedraza, R., Paz, M., Aguirre, W., & Gomez, H. L. (2018). Implementation of computerized physician order entry for chemotherapy: A Latin American experience. JCO Clinical Cancer Informatics, 2(2), 1–12.

Wang, J., Liang, H., Kang, H., & Gong, Y. (2019). Understanding health information technology induced medication safety events by two conceptual frameworks. Applied Clinical Informatics, 10(1), 158–167.

Root Cause Analysis and Safety Improvement Plan Example 2

A root-cause analysis is a method of problem-solving that entails determining the primary reason for a situation or issue to stop it from happening again in the future. An investigation of the root causes of safety problems and potential remedies is often part of a safety improvement plan. Any organization that wishes to increase safety and prevent accidents or incidents must apply root-cause analysis and safety improvement planning.

Organizations may make their workplaces safer and more productive for both their employees and clients by recognizing and addressing the fundamental causes of issues. The purpose of this paper is to conduct a root cause analysis of an incident that risked patient safety in my health organization and develop a safety improvement plan from the analysis.

Analysis of the Root Cause

Mr. X, a 52-year-old black male, had been hospitalized for three days for treatment but was diagnosed with stage II hypertension during his inpatient stay. As part of his treatment plan, he was prescribed Lisinopril tablets, a medication used to lower blood pressure, to be taken once daily at a dosage of 10mg upon his discharge from the hospital.

The medication was dispensed by a licensed pharmacist, who checked that it was the correct medication and had not expired. However, the pharmacist made a mistake and provided the patient with 20mg tablets of Lisinopril instead of the prescribed 10mg tablets.

The patient, who was also a healthcare professional, took the medication as directed and subsequently experienced severely low blood pressure and dizziness, requiring emergency care the next morning. This error occurred despite the pharmacist’s efforts to ensure the accuracy and safety of the medication.

The patient received treatment at the emergency department and recovered from the adverse reaction to the medication. This incident highlights the importance of careful medication management in preventing adverse events and the need for proper training and oversight of healthcare professionals.

The nurses discovered this problem at the emergency department who, during medication reconciliation and health history building, questioned the patient’s past medical and medication history. The nurse wanted to know the reason for this unplanned readmission within 48 hours after discharge.

The patient, Mr. X, was impacted by the issue or event in the scenario mentioned above. Mr. X’s extremely low blood pressure and disorientation were caused by the pharmacist’s mistake in the medication he dispensed, necessitating emergency care. Mr. X had a great deal of stress and inconvenience as a result, and it’s possible that this had a detrimental effect on his physical and mental well-being. The error might have potentially resulted in long-term effects if it hadn’t been caught right afterward.

Patients who experience medication errors may experience adverse side effects, damage, or even death (Assiri et al., 2018). Healthcare providers must adhere to established protocols and procedures to ensure patient safety and minimize avoidable mistakes. Healthcare providers must adhere to established protocols and procedures to guarantee patient safety and minimize avoidable mistakes. Patients should be knowledgeable about their prescriptions and speak out if they have any concerns or inquiries.

Root Cause Analysis

As part of his hypertension treatment plan, Mr. X was given a prescription for Lisinopril pills at a dosage of 10mg once daily and was meant to be discharged from the hospital. A qualified pharmacist was required to dispense the drug and ensure that it was the right one and that it had not expired. However, the pharmacist misread the prescription and gave Mr. X 20mg of Lisinopril tablets rather than the 10mg tablets that were intended.

Despite the pharmacist’s best efforts to ensure the medication’s accuracy and safety, this error nonetheless happened. The usual chain of medication use in the facility is that upon the prescription of medication by the physician or an advanced practice registered nurse, the nurse should check the prescription and obtain the correct medication from the pharmacists.

In case of uncertainty, the nurse, as the professional administering the medication, should check with the prescriber to ascertain that the prescription is safe and appropriate for the patient and that all the five R’s of medication use are considered in the prescription. The pharmacists should ensure that the patient gets the right medication with the correct dose per the prescription.

In cases, of uncertainty, the pharmacist should check with the prescriber and professional administering the medication to prevent errors. Another role of the nurse in this system is ensuring that the patient understands their prescription and is aware of adverse effects, when to seek emergency help, and when to expect clinical improvement.

The environmental factors that played a part in this case can only be inferred from the documented evidence-based literature. In this scenario, the physical environment could have played a part in this issue because of the external distractions in the case of heavy workload in the inpatient pharmacy. Distractions from colleagues or other patients could have deterred the pharmacist from double-checking the dosage strength of Lisinopril dispensed.

The presence of a heavy workload from the high number of patient cases being handled could have played a role in this error. The inpatient pharmacy dispenses medication daily to more than five units in the hospital. Patients being discharged may be highly likely to be overlooked because of the presumed stable condition and thus might not require much attention as opposed to patients requiring emergency care and close monitoring.

The absence of automatic dispensing cabinets for patients being discharged could have influenced this medication error. Barcode medication administration (BCMA) systems could have also prevented this error by assisting the pharmacist in double-checking the prescription.

BCMA and automatic dispensing cabinets can promote medication safety by ensuring that the prescription by the physician or the advanced practice registered nurse could be translated accurately to the dispensing department (Williams et al., 2021). Other technologies can also support or complement these technologies in ensuring medication safety.

The medication provided to the patient may have been incorrect due to several communication-related problems. A breakdown may have significantly influenced the circumstances leading up to this problem in communication between the prescribing doctor and the pharmacist over the appropriate dosage and frequency of the medicine.

This incident might have been caused by a breakdown of communication between the pharmacist and the patient regarding the drug and how to use it properly. The strength of the medication may have been overlooked due to inadequate or unclear documentation or labeling of the drug, which could have caused confusion or misunderstanding.

Nevertheless, written or verbal communication, synchronous or asynchronous, played a critical part in this event. The presence of protocols for communication and guidelines for medication treatment was lacking in this patient’s case. These protocols can ensure accountability and empower teamwork when followed in a coordinated fashion (Russ-Jara et al., 2021). The need for collaboration, leadership, and management is thus evident from the literature.

Application of Evidence-Based Strategies

To address the issue of medication errors, healthcare organizations can implement various best practice strategies. One strategy is to use electronic prescribing systems, which provide accurate and up-to-date medication information and can reduce the risk of errors by eliminating the need for handwritten prescriptions and facilitating communication between prescribing physicians and pharmacists (Mohanna et al., 2022).

Another strategy is to conduct medication reconciliation, which involves reviewing and comparing a patient’s current medications with those prescribed at previous healthcare encounters to ensure that the patient is receiving the correct medications and dosages. Providing ongoing education and training for staff on medication administration protocols, proper labeling and documentation, and error prevention strategies can also help prevent errors (Vaismoradi et al., 2020).

Creating a culture of safety within the organization, where staff feel comfortable reporting errors and identifying potential risks, and implementing a medication error reporting system to identify patterns and trends can also contribute to preventing errors and ensuring patient safety (Mutair et al., 2021). Our healthcare organization must regularly assess its medication management processes and identify potential areas for improvement to prevent errors (Afaya et al., 2021).

According to Chui et al. (2019), addressing medication safety should be multidisciplinary and multifaceted because factors of medication errors cut across more than one discipline and profession. Therefore, these evidence-based strategies would require implementation in all stakeholder departments in our health organization.

Improvement Plan with Evidence-Based and Best-Practice Strategies

A proposed plan for this health organization will include implementing certain additional technologies, regularly training staff on medication safety, establishing an error-reporting system, and developing policies for medication safety.

These strategies can help reduce the risk of errors by providing accurate and up-to-date medication information, facilitating better communication between prescribing physicians and pharmacists, reviewing and comparing a patient’s current medications with those prescribed at previous healthcare encounters, ensuring that staff has the necessary knowledge and skills to safely manage medications, establishing clear protocols for medication management, and identifying patterns and trends in medication errors to allow for targeted interventions (Mohanna et al., 2022).

Specific additional technologies required will be Computerized Physician Order entry (CPOE), BCMA, and automated dispensing cabinets. Impending these technologies would require roughly half a year owing to the lengthy process of procurement, budgetary approval, training staff on their usage, and engaging all stakeholders to evaluate outcomes. However, other strategies such as continuous staff education, establishing error reporting systems, and policy development could be completed in a month after stakeholder consultations.

Existing Organizational Resources

Implementing the above plan would require human, technological, and financial resources. The organization already has healthcare professionals who can implement the plan. However, additional staff in the pharmacy and technology department would make this plan more feasible because it would reduce the workload on the existing human resource.

Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan. The additional resources necessary would require an electronic health record (EHR) or a computerized method of managing patient information. The institution already has an EHR that can complement the BCMA, CPOE, and automated dispensing cabinets.

Most importantly, financial resources would be critical in enhancing this improvement plan. Purchasing the additional technologies, implementing them, and compensating the involved personnel could require additional funds from the institution’s supplementary budget or outside sources.


Root-cause analysis is an essential method for identifying the primary causes of safety issues to prevent them from occurring again in the future. In this case, a root-cause analysis was conducted on an incident in a healthcare organization, where a patient was given an incorrect medication dosage, leading to adverse effects requiring emergency care.

The root cause of this incident was determined to be a mistake made by the pharmacist in reading the prescription and dispensing the wrong dosage of medication. A safety improvement plan was developed to address this issue and prevent similar incidents from occurring in the future.

This plan includes strategies such as implementing an electronic prescribing system, conducting medication reconciliation, providing ongoing education and training for staff, developing clear policies and procedures for medication management, and implementing a medication error reporting system. By implementing these strategies, healthcare organizations can improve patient safety and minimize the risk of preventable medication errors

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan References

  • Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research21(1), 1156.
  • Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aljadhey, H., & Sheikh, A. (2018). What is the epidemiology of medication errors, error-related adverse events, and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open8(5), e019101.
  • Chui, M. A., Pohjanoksa-Mäntylä, M., & Snyder, M. E. (2019). Improving medication safety in varied health systems. Research in Social & Administrative Pharmacy: RSAP15(7), 811–812.
  • Mohanna, Z., Kusljic, S., & Jarden, R. (2022). Investigation of interventions to reduce nurses’ medication errors in adult intensive care units: A systematic review. Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses35(4), 466–479.
  • Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines (Basel, Switzerland)8(9), 46.
  • Russ-Jara, A. L., Luckhurst, C. L., Dismore, R. A., Arthur, K. J., Ifeachor, A. P., Militello, L. G., Glassman, P. A., Zillich, A. J., & Weiner, M. (2021). Care coordination strategies and barriers during medication safety incidents: A qualitative, cognitive task analysis. Journal of General Internal Medicine36(8), 2212–2220.
  • Vaismoradi, M., Tella, S., A Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health17(6), 2028.
  • Williams, R., Aldakhil, R., Blandford, A., & Jani, Y. (2021). Interdisciplinary systematic review: does alignment between system and design shape adoption and use of barcode medication administration technology? BMJ Open11(7), e044419.

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