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 Root-Cause Analysis and Safety Improvement Plan

Identifying the main reason behind a problem helps in avoiding those problems in the future and also helps with making a safety improvement plan that focuses on avoiding those problems and decreasing the adverse events that happen because of those problems. When an event happens in the hospital the nursing staff needs to make sure to study all the factors and then describe the root cause. Correct identification of the root cause will play a key role in making a safety improvement plan that improves the quality of care and patient safety in the healthcare organization. Communication is most commonly considered the main problem in the adverse events happening in hospitals so a well-coordinated system is required to be maintained (Martin-Delgado et al., 2020). 

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Analysis of the Root Cause Related to Hypoglycemia Medication Administration in an Organization

Every disease has its treatment if a person cannot recover fully the most advanced level of treatment is done to make sure the patient feels better than before or at the time he or she came to the hospital. Hypoglycemia is a disease where the blood sugar level of the patient drops. This mostly happens with diabetic patients who are taking medications or are on insulin. This condition can turn life-threatening if not treated on time. If not treated on time patients can even faint and not respond properly. Nurses carried out a root cause analysis of the patients suffering from Hypoglycemia and the solutions advised were having an interdisciplinary approach towards the patients and having a well-coordinated system that takes care of the patient’s needs and supervises and monitors the vitals of the patients to avoid the adverse effects that might be caused by errors. There are several medication errors as well that needs to be avoided such as there are times when due to lack of communication overdose occurs and that can even risk the lives of the patients. It is important to understand the value of a well-coordinated system as while giving them medicines for other reasons like depression or anxiety their current condition of hypoglycemia should be kept in mind as there have been several cases of side effects of the medication advised for other health condition colliding with the current condition. The nurses need to intervene in such cases to reduce the impact and make sure patient safety is maintained. The root cause analysis carried out by the nurses always helps in better understanding and solutions for the patient’s safety and quality of care in the healthcare organization (Shea et al., 2019). 

Application of Evidence-Based Strategies and Best Practices Strategies 

Ensuring patients’ safety and quality of care in the hospital is not something only nurses have to take care of but also the other healthcare professionals should be responsible enough to make sure there are no margins of error that might lead to compromising the quality of care or patient’s safety. It is really important to educate nurses about the factors that can have an impact on the patients’ health. There should be an interactive session in the healthcare organization to make sure the care coordination is being practiced. Coordination and communication are two main elements that are interconnected but these elements contribute the most to maintaining patient safety. As mentioned above medication errors occur there are cases where not understanding the value of coordination has created a mess. The nurses should double-check the prescribed medicines received at the pharmacy by the patients as there are chances of not receiving the right medicines another role of nurses should be when their shift ends they need to inform the next one on the shift about the patient’s health and all the given medications so that the chances of overdosage are minimized (Horntvedt et al., 2018). The patients not taking insulin require a higher level of medical attention as compared to the ones on insulin. The patients should be given the right attention and advice in terms of their diet and the fasting protocols they need to follow. Diabetes patients are advised to take meals within a certain described time frame as that keeps their bodies normal and the required nutrients are received. The best strategy is to adopt an approach that reduces the risk margins in the patients by informing them about the self-management ways through which in case of emergency they can treat themselves. The use of Insulin and Sulfonylurea increases the risk of hypoglycemia so healthcare professionals should carry out a complete test to reduce medication errors and should not prescribe until the case is clear. A team working approach will increase the share of knowledge and experience for the nurse and that will contribute to improved quality of care and patient safety. Social support needs to be given to such patients so that in case of an emergency the family and caretakers know what their role needs to be in this regard (Silbert et al., 2018).

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

Evidence-Based Safety Improvement Plan for Safe Medication Administration

A safety improvement plan for safe medication administration is very important, as it not only increases the patients’ safety but also improves the reputation of the healthcare organization that adopted these methods into their hospital culture. This improves the quality of care and along with that it also gives a competitive advantage to the hospital which means higher profit and they will also be able to receive government grants because of the quality of care provided by them. It is advised by healthcare professionals to guide the patients about self-management several Apps can be installed on smartphones and through them, patients can look at their vitals and do self-medications that are prescribed by the patients. The Apps also keep a complete record of the medications consumed by the patients which helps them in remembering and adding timers to remind them about the medicines and food that need to be consumed in the given time frame. Google Play and Apple have introduced such Apps but these do not only help the patients but also the healthcare professionals as the admitted patient’s history are shared through such Apps and that helps the doctors in analyzing the case more accurately and prescribing the medications accordingly (Huang et al., 2019). Technologies should be introduced that help in monitoring and checking the blood sugar levels in the patients. These technologies are fast and they give the results within minutes for which previously the doctors and patients had to wait for longer and that too lead to risking the patient’s life. The integration of technology helped in a collaborative approach and increased effective decision-making done by the nurses and health care professionals (Grunberger et al., 2021). The improvement plan includes introducing self-management knowledge and awareness that needs to be created among the patients and the nurses must help them understand the process. Apps that help keep a check over the vitals of the patients that are often not sighted due to lack of knowledge and awareness about such Apps are introduced. Integration of technology into the existing system as that will not only benefit the patient’s safety but will also help the healthcare professionals in effective decision making as instead of carrying out a complete test trial all the information is already in one place and that helps in identifying the current health concern. The nurses must always double-check the medications patients receive from the pharmacy and their families and caretakers should be informed about the dosage guidelines for the patients. Electronic medical records should be maintained as that helps in keeping the patients’ information safe and easy to access for the nurses. Healthcare organizations should make sure to provide training programs to the healthcare professionals about the ways the records can be maintained and checked in these new systems. 

Organizational Resources

It is always advised that instead of going for the options that are out of reach the best use of existing resources should also be done to maintain the quality standards and the patient’s safety. Integration of technology into the existing system is no doubt going to increase the cost of the healthcare organization but maintaining a culture that is well-coordinated and well-balanced in terms of the duties and monitoring of the patients will just require some basic efforts and long-term benefits to the organization. At zero cost it is very important to maintain a healthy work environment that allows the nurses to share their stances and opinion on the cases that come into the hospital. Having an open door policy that allows the healthcare professionals to share their views and along with that it also improves the staff motivation that ultimately increases the productivity levels of the nurses. The healthcare organization needs to have a patient-centered approach that puts the health of the patient first and then anything else. The nurse groups should be divided into teams that examine the case and share their views with the doctors, another group should supervise whether the medications are being given at the right time or not. The nursing teams should also be double checking the vitals of the patients before discharging them from the hospital and the medications received from the pharmacy should also be managed and checked. The hospitals should have their known pharmacies it will not only reduce the cost but will also help in minimizing the medication errors that often occur and risks the patients’ life. The Quality Assurance teams should be formed and most importantly drug management needs to be done well. Coordination and removing communication barriers are very important to increase the quality of care and increase the safety of the patients (Stenov et al., 2019). The two organizations have joined together to provide the better guidelines for the diabetic patients. The American Diabetes Association and The European Association for the study of Diabetes have introduced these only the Apps that fall in the category of fulfilling all the medical criteria only such Apps should be advised and no other should be suggested.  All of these organizations put their emphasis on how these Apps can be deceiving in terms of monitoring the vitals so the healthcare professionals and government along with such organizations only inform the patients about the Apps that are verified by the medical board and patients should not rely on any other App (Fleming et al., 2019).

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


Every disease can become life-threatening if not treated in the right way at the right time. It is very important to understand the value of communication and coordination in the healthcare organization as they are the main reason behind conflicts and medication administration errors. The collaborative approach increases the share of knowledge and increases effective decision-making in the organization so maintaining a healthy work culture will keep the healthcare professionals motivated and that will automatically improve the Quality of care and Patient safety. Along with this self-management needs to be guided well not only for the patients dealing with diabetes but for every disease. The government and hospitals need to collaborate to increase awareness and improve the awareness among individuals. Technological advancements should be brought into the hospitals for efficient management of data and monitoring of the vitals of the patients. This will improve their performance and data storing will also become easier. 


Fleming, G. A., Petrie, J. R., Bugental, R. M., Holl, R. W., Peters, A. L., & Heinemann, L. (2019). Diabetes Digital App Technology: Benefits, Challenges, and Recommendations. A Consensus Report by the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) Diabetes Technology Working Group. Diabetes Care, 43(1), 250–260.

Grunberger, G., Sherr, J., Allende, M., Blevins, T., Bode, B., Handelsman, Y., Hellman, R., Lajara, R., Roberts, V. L., Rod bard, D., Stec, C., & Unger, J. (2021). American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons with Diabetes Mellitus. Endocrine Practice, 27(6), 505–537.

‌ Horntvedt, M.-E. T., Norsemen, A., Fermin, T., & Severinsson, E. (2018). Strategies for Teaching Evidence-based Practice in Nursing Education: a Thematic Literature Review. BMC Medical Education, 18(1).

Huang, Z., Lum, E., Jimenez, G., Semwal, M., Sloot, P., & Car, J. (2019). Medication management support in diabetes: a systematic assessment of diabetes self-management apps. BMC Medicine, 17(1).

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

Martin-Delgado, J., Martínez-García, A., Arana-Andres, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of Root Cause Analysis translates to improve patient safety. A systematic review. Medical Principles and Practice, 29(6).

Shea, K. E., Gerard, S. O., & Kinsley, J. S. (2019). Reducing Hypoglycemia in Critical Care Patients Using a Nurse-Driven Root Cause Analysis Process. Critical Care Nurse, 39(4), 29–38.

‌ Silbert, R., Salcido-Montenegro, A., Rodriguez-Gutierrez, R., Katabi, A., & McCoy, R. G. (2018). Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies. Current Diabetes Reports, 18(8).

Stenov, V., Wind, G., Vallis, M., Reventlow, S., & Hempler, N. F. (2019). Group-based, person-centered diabetes self-management education: healthcare professionals’ implementation of new approaches. BMC Health Services Research, 19(1).