NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

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Root-Cause Analysis and Safety Improvement Plan

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

Root cause analysis is a technique used in the scientific community for getting to the bottom of issues and fixing them at their source. When conducting root cause analysis, one must look beyond the obvious causes of a problem. Yet, one can alter the problem-solving paradigm from a search for a single “root cause” to the exposure of a network of interconnected causes. Concentrating on just one root cause may lead you to overlook other, more practical options. There are many potential resolutions, and they can all be found by digging into the root cause. As a result, there are numerous chances to safeguard against potential threats and avoid potential issues (Sheridan, 2022).

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NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

The Root Cause of a Patient Safety Issue

Each year, preventable medical mistakes result in the deaths of about 100 thousand Americans (Watters, 2019).  These fatalities outnumber those from car crashes, breast cancer, and AIDS put together. A nurse in Tennessee gave the wrong medication to the patient. She administered vecuronium instead of Versed as she could not find Versed. To better understand and combat medical errors and prevent future occurrences, a root cause analysis may provide a useful resolution for healthcare professionals and patients. Sometimes it’s hard to pin down exactly what went wrong in a medical setting, but that doesn’t mean we shouldn’t try to figure out how to prevent mistakes from happening in the first place. Root cause analysis is one such technique; it has been shown to be effective in reducing clinical and surgical errors across a wide range of specialties (Brouwers et al., 2019). Medication administration errors involve a wide range of healthcare professionals and can occur at any stage of patient care. The most important tool for avoiding this kind of mistake is open lines of communication. To ensure patients receive the correct medication via the correct dosage and route, it is necessary to communicate for the sake of the patient. Medication errors can occur for a number of reasons, including those related to the packaging, and the system. Clinical pharmacists should strive to enhance nurses’ understanding of how these factors will lead to serious errors and assist in the development of strategies to reduce the occurrence of such errors. The reason for this error can be (1) Overworked nurses are more likely to make mistakes with patients’ medication because of their exhaustion (Brouwers et al., 2019). Inadequate lighting, extreme temperatures, and other environmental factors such as tired nurses, and long hours can all contribute to worker distraction and ultimately, mistakes. (2) Errors can occur when nurses do not have a thorough understanding of a drug, including how it works, its various names (generic and brand), its side effects, its contraindications, etc. (3)Non-Complete Patient Records: Medical mistakes can occur when doctors don’t have complete information about a patient, such as a list of medications they’re taking, a history of any illnesses the patient has had, or the results of any recent lab tests. If a nurse has any doubts, she should check with the doctor or another nurse. (4) It’s possible for a nurse to forget that a patient has an allergy. The nurses should be aware well aware of the patient’s chart and know what medications or injections the patient can have without any problem. Some of the other reasons can be (1) the packaging of the medicines is alike. (2) The pharmacy did not deliver the correct dosage of medicines. (3) Errors occur due to problems in the medication sheets. (4) Nurses get disturbed while giving the medication to the patient. (5) Different patients are on the same medications (Hammoudi et al., 2018). Distractions are a common cause of this. Remembering incorrectly the maximum daily dose for an “as required” medication is another example of a memory-based mistake (Moberg et al., 2018).

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

The Best Strategy for Safety Improvement is an Evidence-based Approach

In the context of patient safety, an event is considered sentinel if it causes (1) Death, Long-term damage, and extremely painful temporary injury requiring medical attention to prevent death. Some of the examples of underlying weaknesses, we can list (1) The Role of Sedation in Radiology, (2) Concerning the absence of standard operating procedures, (3) Inadequate precautions and warnings (4) The Labeling of Medications, (5) Poorly Executed Warn, (6) The absence of a standard operating procedure. Ensure that all prescriptions are filled properly by checking the details of the order (Brouwers et al., 2019). The name of the medication, the dosage, the frequency, and the method of administration should all be specified in order (Watters, 2019). If something seems to be missing, it’s best to double-check with your doctor. To make sure the patient does not have any kind of allergy or contraindication to the medication, you should look it up in their medical history. Do not give the medication if there is an allergy or if there are any contraindications and tell the doctor about it. Each patient’s medication needs to be prepared separately (Trakulsunti et al., 2020). Improve medication safety through patient knowledge. Whenever they notice something is off, they should feel comfortable raising their concerns (Sandra et al., 2022). Some of the evidence-based strategies are (1) You should exercise caution and pay close attention whenever working with pharmaceuticals. Maintaining concentration is crucial. In certain healthcare facilities, such as pharmacies and labs, medication preparation takes place in a no-interruptions zone (NIZ) (Watters, 2019). (2) Be sure to do a thorough evaluation of a patient before administering any medication. (3) When administering medication, it is crucial to first obtain a patient’s vital signs and medical history to ensure the correct dosage and administration time (Alhashemi et al., 2019). A nurse will evaluate a patient’s heart health, for instance, and review lab results before prescribing any cardiac medication. (4) Follow the organization’s established procedures when dispensing medication (Watters, 2019). 

Safety Improvement Plan Applied

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

Evidence-based approaches can be used to deal with the causes of the medication error that occurred here. Automated drug dispensing systems, bar code tracking, and electronic prescriptions are just a few examples of how some hospitals are on the cutting edge of automation and technology to increase the quality of care. More licensed nurses are needed because of efforts to improve medication administration precision (Trakulsunti et al., 2020). Healthcare facilities often spend millions on expensive equipment but cut corners on nurse education and training (Hammoudi, et al., 2018). There are six guarantees that ensure medication is given correctly and efficiently: One of the major tasks to be performed by the nurse is to correctly administer the medication to the patient. Double-check system, which ensures that all medications are administered correctly by requiring a second person to verify each dose (Trakulsunti et al., 2020). All medical professionals have a moral and legal obligation to report incidents of medication errors by filing an “incidence report.” Managers must take responsibility for enforcing consequences for medication mistakes made by nurses and other providers. Thus, it is recommended that mistakes be reported. There should be a medication safety committee in every hospital. Keep your eyes peeled. Watch out for high-alert drugs and situations (Alhashemi et al., 2019). Meds that require a high level of vigilance are the ones that can really mess you up. Respond to patients’ worries. Stop the procedure and do not administer the medication if the patient has any questions or concerns. Ask the patient about their worries, check the doctor’s order, and get in touch if you find anything amiss. The facility should also set up surveillance areas where nurses can be observed to ensure that they are following the established safety and quality protocols for administering medications (Bokhour et al., 2018). Better coordination and adherence to commonly used protocols are two ways in which this strategy hopes to increase safety during the administration of medications. This plan can be implemented in a month if it is worked on seriously. The nurses can be trained and can get registered in workshops and seminars to better understand why it is important to be considerate towards patients and how one can manage to be a better nurse (Alhashemi et al., 2019).

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Organizational Resources and Safety Improvement

A multidisciplinary care team composed of physicians, nurses, and nurse informaticists is one of the organizational resources that will aid in the improvement of the plan’s implementation and outcome. In addition, the computers and other materials in the facility library will be crucial in disseminating information on the current protocol to the care providers. With sufficient funding, academic studies can be conducted that inform the development of instructional materials for new therapeutics. When ensuring that the new protocols are followed, the current surveillance tools can be used (Bokhour et al., 2018). Through its initiatives in education, certification, advocacy, and partnerships with leading healthcare organizations and governmental bodies, the American Society for Healthcare Risk Management (ASHRM) is committed to advancing the field of healthcare risk management and the safety of patients, providers, and the general public. The organizations like (1) The Emergency Medicine Patient Safety Foundation (EMPSF) is dedicated to improving emergency care by increasing awareness of risks and reducing them through training, research, collaboration, and education. Set up a Safety and Health Risk Management Program. (2) Establishing policies to assess the efficacy of an enterprise’s safety and health management systems is encouraged by the Occupational Safety and Health Administration’s (OSHA) Assessment Tool for Hospitals. (3) The Agency for Healthcare Research and Quality (AHRQ) created Team Strategies & Tools to Enhance Performance & Patient Safety to aid organizations in establishing rapid response teams (RRSs) (Bokhour et al., 2018). Make sure everyone on staff has read the company’s safety manual and understands its contents in full. In order to ensure the safety of all employees, management must ensure that everyone in the organization understands their role. New employees should be thoroughly trained in the hospital’s safety procedures, and current employees should be kept abreast of any policy changes in this area. Plan Actions to Ensure Compliance with Safety Regulations Managers in healthcare facilities frequently conduct surprise checks to ensure all employees are performing their duties properly. Institutional governing boards and committees rely on this information to formulate long-term policies. Patient-centered care is often brought up in discussions about service quality improvement (Trakulsunti et al., 2020).


Root cause analysis of a situation helps in performing better as an individual and organization. It highlights that it is not only one problem that results in an error. There are a lot of things that are linked together. Even though there are problems related to medical errors they can be improved by evidence-based methods.


Alhashemi, S. H., Ghorbani, R., & Vazin, A. (2019). Improving knowledge, attitudes, and practice of nurses in medication administration through enteral feeding tubes by clinical pharmacists: a case–control study. Advances in Medical Education and Practice10, 493.

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

Bokhour, B. G., Fix, G. M., Mueller, N. M., Barker, A. M., Lavela, S. L., Hill, J. N., … & Lukas, C. V. (2018). How can healthcare organizations implement patient-centered care? Examinng a large-scale cultural transformation. BMC Health Services Research18(1), 1-11. 

Brouwers, M. C., Florez, I. D., McNair, S. A., Vella, E. T., & Yao, X. (2019, March). Clinical practice guidelines: tools to support high quality patient care. In Seminars in Nuclear Medicine (Vol. 49, No. 2, pp. 145-152). WB Saunders.

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences32(3), 1038-1046.

Moberg, J., Oxman, A. D., Rosenbaum, S., Schünemann, H. J., Guyatt, G., Flottorp, S., … & Alonso-Coello, P. (2018). The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Research Policy and Systems16(1), 1-15.

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

Sandra, P. C., Alba, C. P., & Cristina, M. M. (2022). Use of simulation to improve nursing students’ medication administration competence: a mixed-method study. BMC Nursing21(1), 1-10.

Sheridan, K. (2022). Improving Root Cause Analysis Methods to Analyze Serious Safety Events in Healthcare.

Trakulsunti, Y., Antony, J., Ghadge, A., & Gupta, S. (2020). Reducing medication errors using LSS methodology: A systematic literature review and key findings. Total Quality Management & Business Excellence31(5-6), 550-568., R. (2019). Translation of evidence-based practice: quality improvement and patient safety. Nursing Clinics54(1), 1-20.