NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan
Phillip April 18, 2024 No Comments

Root Cause Analysis and Safety Improvement Plan

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


Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name


Root-Cause Analysis and Safety Improvement Plan

Root Cause Analysis (RCA) serves as a vital method for identifying factors contributing to patient safety risks. Given the significant occurrence of medication administration issues and adverse events in healthcare organizations, patient safety has emerged as a critical concern. RCA plays a pivotal role in reducing preventable adverse events, enhancing patient safety measures, and fostering learning and quality improvement in healthcare settings. Notably, medication errors, including medication administration errors (MAEs), rank among the leading causes of patient safety risks, with studies indicating their prevalence and impact on patient outcomes (Samsiah et al., 2020). This review focuses on analyzing the root causes of drug administration errors in the diabetic ward, with an emphasis on evidence-based safety improvement strategies and organizational interventions to promote patient safety.

Analysis of the Root Cause

Multiple factors contribute to medication administration errors in the diabetes ward. These include inadequate training, deviation from medication administration guidelines, lack of experience, interruptions during medication administration, communication failures, insufficient knowledge, and various human factors. Studies have shown a positive correlation between nursing staff experience and the quality of patient care, underscoring the importance of ongoing training and education (Ulrich et al., 2022). Additionally, communication gaps among healthcare professionals and lack of medication knowledge have been identified as significant contributors to MAEs (Schroers et al., 2020). Deviation from guidelines and interruptions during medication administration also elevate the risk of errors (Wondmieneh et al., 2020). Human factors such as work stress and errors in prescription writing further compound the issue (Brigitta & Dhamanti, 2020).

Application of Evidence-Based Strategies

To mitigate medication administration errors, evidence-based strategies are imperative. Training and education of nursing staff have been shown to enhance patient safety by improving medication accuracy and adherence to the “five rights” of medication administration (Yoon & Sohng, 2021). Technological solutions such as Barcode Medication Administration (BCMA) systems and Clinical Decision Support (CDS) systems offer additional safeguards by reducing errors related to misidentification and providing decision support during drug administration (FitzHenry et al., 2020; Melton et al., 2019). Implementing a culture of safety that encourages open communication and non-punitive error reporting is also essential (Shah et al., 2022).

Evidence-Based Safety Improvement Plans

Safety improvement plans should incorporate root cause analysis findings and evidence-based interventions. Establishing a blame-free culture encourages error reporting, facilitating timely interventions and prevention of adverse events (Carver & Hipskind, 2019). Collaborative efforts between nurses and physicians, along with the use of technological tools and methodologies like Lean Six Sigma, can streamline processes and reduce errors (McDermott et al., 2022). Furthermore, leveraging organizational resources, including healthcare staff, technology, and financial resources, is crucial for successful implementation of safety improvement initiatives.


Root cause analysis provides a systematic approach to understanding and addressing medication errors, thereby enhancing patient safety in healthcare settings. Evidence-based strategies, coupled with organizational resources and a culture of safety, are essential for effectively mitigating medication administration errors and improving patient outcomes.


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 Management, 2020, 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 Making, 19(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 Pharmacy, 42(4), 1118–1127.

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

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 Safety, 47(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 Care, Publish Ahead of Print.

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 Nursing, 19(4), 1–9.

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