NURS FPX 4020 Assessment 2 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 (RCA) is being used widely for understanding factors that are the main reason for medication errors. Instead of keeping the blame on an individual, an identification system of specific factors might contribute to reducing the rate of medication errors. RCA has been performed on a medication incident where competencies of nurses have been evaluated finding the factors that were involved in a medication error. Factors that are majorly involved in medication error include environmental influence, personal (irresponsibility of nurses), unit communication, cultural impact, or lack of education. RCA provides a fair culture for the nursing education system where nursing students and staff identify problems and work on them to find an appropriate solution.

Medication errors are life-threatening for patients and are known to be on 8th number of death causes in the USA. It not only threatens human life but also is crucial to the cost effects of medicines. The root cause of medication errors is to be evaluated from the medicine prescribing process until the administration of medicine. According to root cause analysis results, medication errors are either in the form of incorrect dose, wrong drug registration, incorrect entry list, or wrong medicine formula. 20% of medication errors are due to incorrect order check of medicines, 15.5% are readability errors,14% errors are in terms of a similar name, form, or appearance of medicine, 7.8% are due to the short-hand name of medicine written by doctors while 8.7% are due to incomplete names of medicine written by nurses. Considering patient safety as an important factor and safe hospital services, identification of errors is very important along with finding the causes of error production. RCA helps best in this concern to find the cause and apply strategies to overcome the medication errors (Rezaei., 2019).

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RCA helps nurses in the identification of systematic or other reasons for occurrence along with immediate error causes. Along with identifying the direct source of error/problem, identification of the root cause is also necessary. Finding the direct error source can be helpful for a short period but it will not completely cure the issue while finding of root cause will be beneficial enough that not the same type of error can occur again. Responsible health professionals or nurses for the medication error should provide a pre-determined answer for each cause. From the outcome of the RCA analysis, it is suggested to implement error prevention strategies that should focus on policies and procedures along with strong communication among physicians, healthcare professionals, and nurses. Understanding the root cause has clinical significance to find preventive measures for medication errors.

Analysis of the Root Cause

Risk management is a complex combination of clinical and administrative procedures that detect, assess, and prevent patients from risk. The healthcare organizations have a systematic way of evaluation through RCA which helps optimize the patient care and implementation of plans to reduce medication errors. RCA keeps the individuals focused on systematic procedures by which individuals’ activities can be analyzed. RCA enhances the performance of patient safety and improved healthcare facilities. Combined RCA analysis of sentinel events can play a key role in improving an organization’s healthcare facilities and patient safety procedures by providing the risk factors and root causes of problems. RCA has been performed in a regional teaching hospital in the Netherlands, by combining the key characteristics and variables of sentinel events to find the pattern of causative factors that are involved in error production or failure of any plan/event. 

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

Clustering 21 events with 21 patients who were having multidisciplinary care and some resulted in permanent harm or injury. 132 root causes were identified and about 53.8% were human errors while 40.2% were organizational causes. 3% of factors were identified as technical faults or patient behavioral factors. To overcome these factors, an organization aimed to improve strategic plans that could focus on the care of elder patients by providing multidisciplinary care. Improving knowledge and revision of certain protocols. Variable clustering of sentinel events and factors that contribute to using RCA can help the hospital management identify and find insight into risks and their trending patterns in an organization. RCA analysis determines the best strategies to improve safety or sentinel events in an organization that can benefit the medication administration process (Hooker AB et al., 2019). 

Application of Evidence-Based Strategies

Taking about a single sentinel event, prevention strategies to be applied that aim to improve the working environment locally and on an organizational level. Findings of RCA, hospital protocols were designed along with coordination of nurses and medical staff. Aspects that are important to patient safety and care are explained from patient admission to diagnosis, to treatment and discharge. The job description of medical specialists was updated that clearly describes the coordination of healthcare workers with interdisciplinary teams and explanation of protocols to healthcare providers and nurses in terms of patient care and medication. Application of knowledge-based approaches to improve the quality and behavior of regular examination of safety measures in a department (Hooker AB et al., 2019).

  The most important strategy is how we respond to sentinel events. Since 2007, summary data shows approximately 800 yearly sentinel events have been reported in Joint Commission. Most of the sentinel events occur in medical or surgical hospital sites along will psychiatrically wards and emergency units. A good response to a sentinel event can be stabilizing the patient, reporting patient and family about the actual event, giving them support, keeping hospital leaders confident about the event, investigating the cause, RCA to find factors involved, formulating a timeline to implement action plan approved by the system (Patra and Jesus., 2021).

There are more chances of medication errors when nurses or physicians are interrupted during medicine administration to patients which affect the life of the patient. The cases of medication error due to work interruption incidents were found to be 1,152 (Getnet & Bifftu., 2017). The study was carried out in 3 hospitals in Amhara Regional State, Northwest Ethiopia. Out of 278 nurse participants chosen for the study, 222 experience work interruption more often during medication administration (Getnet & Bifftu., 2017). The results also showed that most interruptions were during the weekend when nurses do not get attention to medicine administration properly due to surrounding activities or due to enjoying the weekend charm while on duty. This needs to be improved by conducting an administrative meeting where tasks should be assigned to specific nurses under the supervision of senior staff members, so medication errors are reduced to promote patient safety/care (Getnet & Bifftu., 2017). 

Improvement Plan with Evidence-Based and Best-Practice Strategies

Preventive measures can be taken to minimize sentinel events on priority making sure about the cause of the event. Mainly 2 steps to be taken as the best strategy to respond to sentinel events which include system-based investigation of the cause of the event through root cause analysis and making a corrective action plan. Finding out what exactly happened, why it happened, and what are the latent conditions. Healthcare system design may have certain conditions about an incident that includes a provider having policies and layouts, the procedure to inherit the risk, products or resources like medical devices, peripherals (hospital infrastructure and surrounding factors, capability to prevent accidental treatments, and outdated policies.

Applying the strategy to an effective action plan that should address identification of corrective actions to control system hazards, implementation of action plans, timely completion of the action plan, applying strategy to evaluate how effective the plan is working along with strategies that sustain the change. Conductive a root cause analysis followed by a corrective action plan is the best strategy so far which is also called Sentinel Event Measure of Success (SE MOS) implemented by the Joint Commission in 2020 (Mc Gowan., 2022). The SE-MOS strategy can be beneficial with teamwork and cultural transparency to enhance patient safety protocols and investigate causes of sentinel events for the implementation of preventive measures (MC Gowan., 2022). 

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

Existing Organizational Resources

First, nurses should be trained to report the events immediately so the appropriate action can be taken timely. Strong communication channels to be projected as a tool in healthcare organizations. Unlawful use of drugs to be prohibited in the hospital during medicine administration procedures. A proper plan to assess the organizational resources of healthcare staff, nurses, and physicians in case of any sentinel event. Implementation of Medication Error Reporting System (MEDMARX) effectively in case of any medication error or sentinel event. MEDMARX is adopted in the U.S. for immediate error reporting. MEDMARX is an error reporting system that can be used through the internet as it is a cloud-based server (Anderson & Abrahamson., 2017). 

    Use of available resources in case of a sentinel event will save from further damage. It includes the application of care management, devices, surgical procedures to save patients, and evaluation of the cause of the event using available resources in the hospital at moment. Identify the trends in systematic procedures. Apply strategies addressed to drop the medication error rate and increase patient safety practices. IT-based resources that include the use of electronic media records, bar code information, and decision support systems are considered a good immediate source to respond to medication errors. Investing in these technologies is found to be very effective in promoting patient safety (Anderson & Abrahamson., 2017).


Medication errors are very common in healthcare settings and are a big concern globally. Root cause analysis is used by many researchers to find out the cause of sentinel events that happened in the hospital settings and implement a corrective action plan to overcome the loss. RCA allows healthcare hospitals to focus on patients’ health requirements and set the goals that meet the patient’s needs. From RCA analysis, hospital management will be sure about the steps to be taken to prevent any further mishappening due to causative factors and take measures so the reoccurrence of sentinel events can be prevented. 


Anderson, J. G., Abrahamson K. Your Health Care May Kill You: Medical Errors. Stud Health Technol Inform. 2017;234:13-17. 

Getnet, M. A., & Bifftu, B. B. (2017). Work Interruption Experienced by Nurses during Medication Administration Process and Associated Factors, Northwest Ethiopia. Nursing Research and Practice2017, 8937490. 

Hooker, A. B., Etman, A., Westra, M., Van der Kam, W. J. Aggregate analysis of sentinel events as a strategic tool in safety management can contribute to the improvement of healthcare safety. Int J Qual Health Care. 2019 Mar 1;31(2):110-116.

Jain K. Use of failure mode effect analysis (FMEA) to improve medication management process. Int J Health Care Qual Assur. 2017 Mar 13;30(2):175-186. 

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

Johnson M, Sanchez P, Langdon R, Manias E, Levett-Jones T, Weidemann G, Aguilar V, Everett B. The impact of interruptions on medication errors in hospitals: an observational study of nurses. J Nurs Manag. 2017 Oct;25(7):498-507. 

McGowan J, Wojahn A, Nicolini JR. Risk Management Event Evaluation and Responsibilities. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: 

Patra KP, De Jesus O. Sentinel Event. [Updated 2021 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: 

Ramadaniati HU, Hughes JD, Lee YP, Emmerton LM. Simulated medication errors: A means of evaluating healthcare professionals’ knowledge and understanding of medication safety. Int J Risk Saf Med. 2018;29(3-4):149-158. 

Rezaei, T. (2019). Analysis of medication errors by RCA method and implementation of reducing strategies to improve patient safety in Hujjat Kuh-Kamari Hospital in Marand-2017. Journal of Injury and Violence Research11, 1-2.