NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan

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Root Cause Analysis & Safety Improvement Plan

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan

There needs to be an emphasis on mitigating the factors that cause adverse events like medication errors. The specific safety concern that has been recognized was with the young patient Sam who was diagnosed with cancer. Upon difficulty eating he was given an infusion pump, it was brought to the nurse’s knowledge 5 hours later that the infusion rate was incorrect. More such cases occur in the healthcare facility, some also go unreported. 

Root cause analysis is highly helpful as it allows medication errors to be identified. Since medication errors are common and avoidable, root cause analysis allows for addressing important patient care aspects (Singh et al.,2022). It allows important steps to be taken to improve communication and different facilities to prevent medication errors.  This paper will help analyze the root causes of patient safety issues, apply evidence-based strategies to that issue, and create a safety improvement plan. 

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Analyzed the Root Cause of Patient Safety Issue

The patient safety issue as discussed before is the infusion pump in this paper. 1,004 events of medication error were recorded in 2018 across Pennsylvania that involved the use of an infusion pump. Some of these cases were of high alert and concern (Taylor & Jones, 2019). User programming was identified to be the major cause of this issue. Either the IV is not connected properly, the device malfunctions, the device is not maintained properly, or the patient intentionally or unintentionally programmed the pump themselves.
Among several medication errors, infusion pump errors have been identified to be one of the most prevalent. The carelessness or lack of communication can cause incorrect programming that may lead to such errors. The patient may even avoid programming themselves if there was proper communication not only amongst the nurses but with the patient too about their treatment. Infusion pumps can cause inefficiencies leading to errors largely due to time taking indirect patient care tasks that are associated with infusion pump procedures like searching for pumps, manual programming, responding to false pump alarms, managing tangled tubes, and priming tubing (Bacon et al., 2020). Such inadequate workflows lead to inefficient communication, delays, and care gaps. It is also important to highlight that lack of training and knowledge can lead to a lot of rule-based mistakes with infusion pumps. 

Applying Evidence-Based Strategies to Address this Safety Issue

The harm that such errors with infusion pumps cause is considered to be a major failure of the health care facility and should be mitigated to gain patient trust and ensure their safety. A series of tests were done by a multidisciplinary team on infusion pumps and different approaches were identified (Porte et al., 2020). The 2-person verification approach was considered to be the best to reduce error and prevent time delays.

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan

An important step would be to invest in the training of nurses for the correct maintenance, usage, and monitoring of infusion pumps. Another crucial step of implementation should focus on designing the workflows again and structured process changes so that the efficiency of the pump is better. These steps focus on the nurses as they work closely with the patient so they have an important role when handling materials. The streamlining and standardization of the processes has been proved to be good facilitator along with education or training to reduce medication errors (Bacon et al., 2020). Such strategies would help patients like Sam get the appropriate rate when getting infusion pumps, and increase their quality of care as nurses would be more educated, have more awareness, and follow a streamlined workflow. Implementation of technology can also prevent the wrong rate or doses as the programming would be automated rather than manual, providing an alarm or notification system in cases of any negligence. 

Viable Evidence-Based Safety Improvement Plan

The best safety improvement plan that would involve the right strategies to mitigate the errors associated with wrong doses or rates being set such as in the case of infusion pump would be to create a multidisciplinary team. Multidisciplinary teams allow effective collaboration and communication, and the assigned leadership roles in this team can allow the team members to follow protocols strictly. The division of tasks in such a team would avoid workload and indirect patient care tasks related to the infusion pumps could be divided so there is no undivided attention when setting up a pump. This improvement plan should also consider training the working staff and providing them education to handle different technology, and maintenance of devices, knowing high-risk drugs, recognizing medication errors, and recognizing the consequences related to medication errors. 

Integration of smart and modern pumps are being incorporated to prevent errors. Institute for Safe Medication Practices (ISMP) recommends using smart infusion systems that have a barcode reader so they can be linked with electronic health records (Taylor & Jones, 2019) This would save the nurses from manually entering the information which would significantly prevent errors. There should be an urge to promote multidisciplinary teams including all the frontline staff and relevant stakeholders to consider pump designs, be involved in decision-making, and consider safety-related features. This team would also apply improvement processes for quality to review data and provide solutions. Such processes have proven to produce a range of improvements in health care facilities (Taylor & Jones, 2019). Several literature reviews of evidence show that the workflows and protocols are important to any use of technology and should be considered when using smart infusion pump technologies (Bacon et al., 2020). The evidence has also supported the education to promote the safe use of infusion pumps (Bacon et al., 2020). Such streamlining of workflows and implementation of protocols can only come about in a multidisciplinary team to promote a safe environment. 


The timeline for the implementation of this strategy will take about 2 months. The first month will be for policy-making and strategizing with the administration and executive members, along with giving training and refresher courses to the nurses at the same time. After this period is completed and the policy is made, the second month will be used to implement the new policy and guidelines for reducing medication administration errors. If improvement is seen then the policy will be finalized and for the nurses, the courses will continue on as deemed necessary.

Existing Organizational Resources That Could be Leveraged

Nurses must know about utilizing the organizational resources effectively to reduce costs and errors too. Organizational managers or administrators should set up a multidisciplinary team to divide tasks. Interventions of smart infusion pumps with the newest technology can be provided to the nurses to save time. There should be an error reporting program in the organization so no medication error is unreported and all the cases can be analyzed from the root to avoid them in the future.

For medication error reporting programs to be successful, it should be safe for the one reporting so effective changes can be made along with useful or constructive recommendations. The organization must adopt an environment that is effective for reporting medication errors to make it a better practice (Mutair et al., 2021). 

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With the cases of medication errors increasing, there needs to be ways or strategies to mitigate these. Infusion pump rate errors have significantly been reported and are mostly due to lack of education, a burden on nurses due to other tasks, and manual time-consuming programming. With the intervention of smarter pumps and multidisciplinary teams, there could be a standardized workflow with protocols that would lead to fewer errors. 


Bacon, O., & Hoffman, L. (2020). System-level patient safety practices that aim to reduce medication errors associated with infusion pumps: An evidence review. Journal of Patient Safety, 16(3), S42–S47.

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan

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 improve reporting systems. Medicines, 8(9), 46.

Porte, P. J., Verweij, L. M., Collares, C. F., de Bruijne, M. C., van der Vleuten, C., & Wagner, C. (2020). Improving the competency of nurses. Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 43(6), 357–368.

Singh, G., Patel, R., & Boster, J. (2022). Root cause analysis and medical error prevention [E-book]. StatPearls.,improve%20patient%20care%20and%20safety.

Taylor, M., & Jones, R. (2019). Risk of medication errors with infusion pumps. Patient Safety, 61–69.