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

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

Root-Cause Analysis and Safety Improvement Plan

Root-cause analysis is a crucial method for understanding the reasons behind medication errors and taking steps to prevent them in the future (Singh et al., 2021). Such errors can have fatal consequences, impacting patient care and well-being. This assessment focuses on analyzing the root causes of medication errors and proposing evidence-based strategies to prevent future incidents. Additionally, it identifies existing organizational resources that can support the implementation of these strategies.

Root Causes of Medication Errors in Healthcare Delivery

Medication errors during the medication administration process can lead to serious patient safety issues and are considered sentinel events that require immediate investigation and response. Several root causes contribute to medication errors, including human factors, communication breakdowns, process problems, and systemic issues (Singh et al., 2021).

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

The root cause analysis of the medication error incident involving the 45-year-old male patient revealed several contributing factors. Firstly, there was a lack of communication between the healthcare team members regarding the patient’s medical history and allergies. The nurse who administered the medication did not properly review the patient’s medical record, which contained vital information about his allergy to the medication. The lack of standardization in the medication administration process also contributed to the error, as there were no established protocols or checklists to follow. Additionally, the healthcare facility’s culture may have played a role in the incident, as there may have been a lack of emphasis on patient safety and quality improvement. The investigation also found that the nurse responsible for the error may not have received adequate training and education on medication administration and patient safety. To prevent similar incidents in the future, the root cause analysis recommends implementing standardized medication administration protocols, improving communication among healthcare team members, emphasizing patient safety in the facility’s culture, and providing ongoing education and training for healthcare professionals.

Elements Contributed to Safety Issues

In healthcare settings, multiple factors can contribute to safety issues, such as human factors like fatigue or distraction and system failures such as faulty equipment or inadequate protocols.

  • Human factors, such as inadequate staffing, lack of training, fatigue, stress, and distractions, can contribute to medication errors (Faraj Al-Ahmadi et al., 2020). For instance, a nurse who has a high patient load may become fatigued and accidentally administer the wrong medication or dose.
  • Medication errors can also occur due to lack of communication (Tiwary et al., 2019). Unclear medication instructions from physicians or miscommunication during handoff between care providers can result in administering the wrong medication or dose.
  • Process problems, such as improper labeling or storage of medications, can contribute to medication errors (Tariq & Scherbak, 2022). For instance, if medications are not correctly labeled or stored, a nurse may mistakenly administer the wrong medication.
  • Systemic issues within the healthcare organization, such as inadequate access to electronic health records or medication information, can also lead to medication errors. For example, if a nurse does not have the latest medication information, they may inadvertently administer an incorrect dose.

Application of Evidence-Based Strategies

To address the medication error that occurred in the given scenario, the following evidence-based and best-practice strategies can be implemented:

  • Medication Reconciliation: This strategy involves comparing the patient’s medication orders with the list of medications they are currently taking to identify any discrepancies, such as allergies or drug interactions. Medication reconciliation is a process that can assist in reducing medication errors during hospital admission, transfer, or discharge (Patel et al., 2019). The nurse responsible for administering medications should have access to the patient’s medication list and should perform a thorough check before administering any medication.
  • Barcoding and Scanning Technology: Barcoding and scanning technology can be used to reduce medication errors by matching the medication order with the patient’s identification bracelet and the medication label (Mulac et al., 2021). This technology can help prevent medication errors due to human error or miscommunication by providing an electronic record of the medication administered.
  • Education and Training: Nurses and other healthcare professionals should be trained and educated on medication administration, including proper identification and management of allergies and drug interactions. 
  • Electronic Health Records (EHR): Electronic health records can help prevent medication errors by providing up-to-date information on the patient’s medical history, allergies, and medications (Mills, 2019). The EHR system should be accessible to all healthcare providers involved in the patient’s care to ensure accurate and timely communication of medication information.

How Strategies will Address Safety Issues?

The hospital will implement a series of evidence-based strategies to address the medication error that occurred with the 45-year-old patient. These strategies include conducting a thorough medication reconciliation process to ensure accurate medication administration, utilizing computerized physician order entry (CPOE) to minimize communication errors, implementing barcode scanning technology to verify medication administration, and providing ongoing education and training for healthcare staff on safe medication practices. These strategies will improve medication safety and prevent future errors.

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

Overall, the hospital is committed to ensuring the safety and well-being of its patients through the implementation of evidence-based strategies. By utilizing technology, improving communication, and providing ongoing education and training for staff, the hospital aims to reduce medication errors and improve patient outcomes. Through continuous evaluation and improvement of medication administration processes, the hospital will maintain a culture of safety and continually strive to provide the highest quality of care for its patients.

Improvement Plan with Evidence-Based and Best-Practice Strategies

To enhance patient safety and minimize medication errors in healthcare organizations, it is crucial to establish a multidisciplinary team comprising doctors, nurses, and physicians to develop a comprehensive plan (Hughes, 2018). The team should set practical goals and analyze the situation to achieve them. Healthcare providers should receive regular education and training on medication administration and safe practices, using simulation training and interactive case studies. Additionally, ongoing professional development through short courses, conferences, and workshops can help keep healthcare providers up-to-date on current best practices in medication safety (Mutair et al., 2021).

One effective strategy to reduce medication errors is to implement BCMA technology to reduce nurses’ workload and burden (Mulac et al., 2021). Furthermore, healthcare organizations can recruit more staff to avoid excessive workloads on healthcare providers. Implementing these improvement plans can reduce patient mortality rates and improve patient quality of care.

It is essential to establish laws and regulations to enhance patient safety and ensure that every staff member follows these rules and regulations to prevent medication errors. By implementing these strategies, healthcare organizations can improve patient welfare and reduce the incidence of medication errors.

Existing Organizational Resources

To ensure the successful implementation of any safety improvement plan, such as safe medication administration, it is crucial to have adequate organizational resources. These resources include appropriate staffing levels, workload management, time management, and budget management. Budgeting is particularly critical in ensuring the success of a strategy. Pre-budgeting must be done with consideration given to every expenditure, and a finance specialist should be involved in the planning team.

Effective time management is also essential to the success of the plan (Mutair et al., 2021). The workload must be distributed among the team members to ensure that the plan remains reliable. Allocating shift responsibilities to each staff member can reduce the burden on healthcare providers and allow them to focus more on patients. The process of training and recruiting new employees can be both time-consuming and costly. NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan. Therefore, it is recommended to utilize existing staff to avoid compromising the quality of the strategy.

Leveraging existing organizational resources can have a significant impact on the implementation of the safety improvement plan. Effective budget management and workload distribution can reduce the burden on healthcare staff and improve patient care. Implementing these strategies can help minimize medication errors and enhance patient safety and quality of care within the healthcare organization


Developing and implementing a safety improvement plan for medication administration requires a multidisciplinary team approach, regular education and training, the implementation of technology such as BCMA, and the effective use of organizational resources such as budget management and workload distribution. By prioritizing these resources and strategies according to their potential impact, healthcare organizations can reduce medication errors, improve patient safety and outcomes, and enhance the overall quality of care provided.


Faraj Al-Ahmadi, R., Al-Juffali, L., Al-Shanawani, S., & Ali, S. (2020). Categorizing and understanding medication errors in hospital pharmacy in relation to human factors. Saudi Pharmaceutical Journal, 28(12). 

Hughes, C. (2018, July 12). Multidisciplinary Teamwork Ensures Better Healthcare Outcomes. 

Mills, S. (2019). Electronic health records and use of clinical decision support. Critical Care Nursing Clinics of North America, 31(2), 125–131. 

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. 

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, 8(9), 46. 

Patel, E., Pevnick, J. M., & Kennelty, K. A. (2019). Pharmacists and medication reconciliation: a review of recent literature. Integrated Pharmacy Research and Practice, Volume 8, 39–45. 7

Singh, G., Patel, R. H., & Boster, J. (2021). Root cause analysis and medical error prevention. PubMed; StatPearls Publishing. 

Tariq, R. A., & Scherbak, Y. (2022, July 3). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. 

Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor communication by health care professionals may lead to life-threatening complications: examples from two case reports. Wellcome Open Research, 4(1). 

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