NURS FPX 4020 Assessment 2
Phillip September 15, 2023 No Comments

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

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

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NURS FPX 4020 Improving Quality of Care and Patient Safety

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Root-Cause Analysis and Safety Improvement Plan

Root Cause Analysis (RCA) is an efficient approach to determine the factors pertaining to patient safety risks. Because of a high incidence of medication administration issues and adverse events in the healthcare organization patient safety has gathered immense attention and has been found to be of paramount importance. RCA has an important role in reducing preventable adverse events improving patient safety measures, and improving learning and quality in healthcare settings. Medication errors account for the eighth leading cause of death in the USA. Medication errors, particularly medication administration errors are leading factors contributing to patient safety risks. A number of studies have reported that MAEs are among the most common medical errors to occur in acute care settings as well, leading to an extended hospital stay (Samsiah et al., 2020). This review is particularly aimed at analyzing the root causes of drug administration errors causing patient safety issues in the diabetic ward. In this analysis, patient safety issues or sentinel events pertaining to medication administration will be discussed, with the main focus on evidence-based safety improvement strategies and organizational interventions that could be used to promote patient safety

Analysis of the Root Cause

Various factors can be attributed to being the root cause of medication administration error to Mr. Wallace in the diabetes ward. The potential root causes of medication administration error discussed in Assessment 1 include the lack of adequate training, deviation from guidelines for medication administration, inadequate work experience, interruption during medication administration, inefficient communication, lack of sufficient knowledge, and some human factors leading to errors pertaining to patient safety issues. 

Nursing staff with inadequate training make mistakes more often than the nurses who regularly receive training on nursing practices and pharmaceutical knowledge. A study depicted a positive correlation between the experience of nursing staff and the quality of patient care administered by them (Ulrich et al., 2022). Lack of communication between the nurses, clinicians, and other colleagues in the healthcare setting often results in medication administration errors by the nurses. 

A qualitative evaluation done to provide qualitative evidence of nurses’ reported causes of MAEs, suggested lack of medication knowledge to be the predominant knowledge-based issue (Schroers et al., 2020). The unavailability of appropriate guidelines and deviation from medication administration guidelines increases the risk of MEs done by nurses up to twofold (Wondmieneh et al., 2020). MAEs can be prevented by minimizing interruptions during the medication administration process. Human error due to work stress, errors in prescription writing or transcribing, and lack of work experience, etc. contribute to about 19.4% of MAEs (Brigitta & Dhamanti, 2020).

Application of Evidence-Based Strategies

To address the obstacles that contribute to safety issues related to medication administration errors in hospitalized patients, evidence-based solutions are necessary to establish a safety culture and improve nurses’ competence. Since nurses are the key personnel in establishing accurate medication lists, detecting anomalies, and preventing mistakes caused by drug interactions or omissions, training and education of nurses have a positive impact on the reduction of medication administration errors (Yoon & Sohng, 2021). Nurses can enhance the accuracy of drug history and prevent adverse events by actively involving patients, their families, and other healthcare providers in the process. The majority of the errors of the drug administration stage can be avoided by nurses during drug administration to the patient by ensuring the “five rights” (the right patient, the right drug, the right dose, the right route, and the right time) of pharmaceutical administration. The BCMA System has also shown considerable benefits in terms of reducing the likelihood of administrative mistakes due to misidentification or miscommunication (FitzHenry et al., 2020). The use of a Barcode Medicine Administration (BCMA) system also aids in the confirmation of these “five rights” of medicine administration. 

The use of smart infusion pumps with Dose Error Reduction Systems (DERS) is a successful approach for reducing intravenous drug delivery mistakes (Melton et al., 2019). Clinical Decision Support (CDS) Systems are cognitive tools that help nurses make educated judgments during drug administration. Independent double-checks for high-risk medications, aid in risk mitigation, and provide additional safety precautions during administration. It is critical to foster a culture of safety and open communication for nurses to disclose errors and near-misses without fear of retaliation. Organizations should set up non-punitive reporting procedures to uncover system flaws so that the root causes of errors can be analyzed and addressed. 

Evidence-Based Safety Improvement Plans

Safety improvement plans are developed with the purpose of reducing errors leading to adverse events. These plans include the systematic incorporation of root cause and error-based multiple-solution strategies. Establishing a blame-free culture where the main focus relies on the causes of errors and not on the human responsible for the error, can result in subsequent reporting of medication administration errors thus leading to timely interventions and prevention of morbidities (Carver & Hipskind, 2019). Effective communication and collaboration between nurses and physicians have been found to have a positive impact on the quality of patient care provided in hospitals (Visvalingam et al., 2023).

Root-Cause Analysis and Safety Improvement Plan

The implementation of technological tools such as BCMA and CDSS effectively aid in delivering accurate medication administration by streamlining the process of medication administration and maintaining accurate patient record.  The methodology of Lean Six Sigma Plus has been used extensively in hospitals with the aim of reducing medication errors. LSS uses the combined processes of Lean and Six Sigma to reduce the wastage of resources and identification of defects and variabilities. LSS can be particularly helpful in streamlining the processes and reducing medical errors. It works by standardizing the protocols and enhancing patient satisfaction (McDermott et al., 2022).

Organizational Resources

To get the maximum impact of a comprehensive safety improvement plan, existing and potential organizational resources must be optimally used. Organizational resources at the hospital level can include the healthcare staff present in the hospital setting, technological tools used by the healthcare systems, strategies in action, and financial resources of the healthcare setting. Healthcare settings should deliver updated knowledge and training to the staff members via the incorporation of frequent in-service sessions. Healthcare settings that invest in technologically advanced tools to provide patient care have been often found to have reduced the occurrence of adverse events, especially during medication administration.

Organizations should develop strategies aimed at promoting the reporting of adverse events by nurses and other healthcare practitioners and taking interventions to prevent adverse events. Financial resources of the hospitals can be employed in providing training to the healthcare staff and to induct the technological tools in patient care. NURS FPX 4020 Assessment 2- Root-Cause Analysis and Safety Improvement Plan. The multidisciplinary teams within the healthcare setting and professional organizations such as the can also be included in the resources of the healthcare organization as these organizations foster professional development, standardization, and best practices in the hospitals by conducting research studies, promoting evidence-based practices, disseminating guidelines and standards related to medication administration, and offering ongoing education and training subsequently resulting in a reduction in adverse events. 


Acute care settings may experience medication errors for a number of reasons. In order to systematically ascertain the underlying causes and prevent future occurrences, the root cause analysis of medication errors is necessary that may contribute to patient safety issues or sentinel events is helpful. NURS FPX 4020 Assessment 2- Root-Cause Analysis and Safety Improvement Plan. Evidence-based approaches are required to overcome these barriers contributing to safety issues or sentinel occurrences associated with medication administration errors. In order to underline the need for action after the study is finalized, the LSS approach used provides a thorough and dependable solution. The organizations such as the Nursing Associations and MSOS can be utilized effectively in order to maximize the potential impact of a complete safety improvement plan.


Carver, N., & Hipskind, J. E. (2019, April 28). Medical Error.; StatPearls Publishing. 

FitzHenry, F., Eden, S. K., Denton, J., Cao, H., Cao, A., Reeves, R., Chen, G., Gobbel, G., Wells, N., & Matheny, M. E. (2020). Prevalence and risk factors for opioid-induced constipation in an older national Veteran cohort. Pain Research and Management2020, 1–11.

McDermott, O., Antony, J., Bhat, S., Jayaraman, R., Rosa, A., Marolla, G., & Parida, R. (2022). Lean six sigma in healthcare: A systematic literature review on motivations and benefits. Processes, 10(10), 1910. 

Melton, K. R., Timmons, K., Walsh, K. E., Meinzen-Derr, J. K., & Kirkendall, E. (2019). Smart pumps improve medication safety but increase alert burden in neonatal care. BMC Medical Informatics and Decision Making19(1).

Samsiah, A., Othman, N., Jamshed, S., & Hassali, M. A. (2020). Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics. International Journal of Clinical Pharmacy42(4), 1118–1127.

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1).

Shah, F., Falconer, E. A., & Cimiotti, J. P. (2022). Does root cause analysis improve patient safety? A systematic review at the department of veterans affairs. Quality Management in Health CarePublish Ahead of Print.

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

Ulrich, B., Cassidy, L., Barden, C., Varn-Davis, N., & Delgado, S. A. (2022). National Nurse Work Environments – October 2021: A Status Report. Critical Care Nurse, 42(5), e1–e18. 

Visvalingam, P. A. A., Hamid, S. B. A., Basha, M. A. B. M. K., & Atan, A. (2023). A systematic review of knowledge, attitude, practice and the associated factors of medication error among registered nurses. IJFMR – International Journal for Multidisciplinary Research, 5(4). 

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

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(4), 1–9. 

Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting system. Nursing Open.