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

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Assessment 2: Root Cause Analysis and Safety Improvement Plan
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Student Name
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Capella University
Course Name
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Prof Name
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FEB 23, 2024
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Root Cause Analysis and Safety Improvement Plan rv
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Medication errors in healthcare settings pose significant risks to patient safety, with medication
administration errors being a leading cause of mortality in the USA. This paper examines the
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root causes of medication administration errors within a healthcare organization's diabetic ward
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and proposes evidence-based strategies to improve patient safety.

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Analysis of the Root Cause

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Mr. Wallace's experience in the diabetic ward highlights several root causes of medication
administration errors. These include inadequate training, deviation from guidelines, lack of work
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experience, interruptions during administration, communication inefficiencies, lack of

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knowledge, and human factors contributing to errors. Research indicates a positive correlation
between nursing staff experience and the quality of patient care. Communication gaps among
healthcare professionals often lead to medication errors, while insufficient medication knowledge
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and guideline deviations elevate error risks. Minimizing interruptions during administration and
addressing human factors such as work stress are crucial steps in error prevention.
Application of Evidence-Based Strategies
To mitigate the obstacles contributing to safety issues, evidence-based strategies are essential.
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Nurse training emphasizing the "five rights" of pharmaceutical administration is crucial for error
reduction. Implementing Barcode Medication Administration (BCMA) systems and Smart
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infusion pumps with Dose Error Reduction Systems (DERS) and Clinical Decision Support
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(CDS) Systems has been shown to significantly decrease errors. Cultivating a safety culture,
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promoting open communication, and establishing non-punitive reporting procedures are essential
for addressing errors and enhancing patient safety.
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Evidence-Based Safety Improvement Plans
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Safety improvement plans aim to reduce errors through systematic root cause analysis and
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multi-solution strategies. Establishing a blame-free culture facilitates timely interventions.
Effective communication and collaboration between healthcare professionals positively impact

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patient care quality. Implementing technological tools such as BCMA and CDSS streamlines
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medication administration. The Lean Six Sigma Plus methodology proves valuable for
minimizing errors in hospitals.

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Organizational Resources
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Optimal utilization of organizational resources is essential for maximum impact. Hospitals
should invest in staff training, technologically advanced tools, and strategies for patient care.
Financial resources can support staff training and technological tool incorporation. Involving
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multidisciplinary teams and professional organizations enhances standardization and best
practices, ultimately reducing adverse events.
Conclusion
Systematic root cause analysis is essential to prevent future medication errors in acute care
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settings. Evidence-based approaches provide comprehensive solutions. Leveraging organizations
like Nursing Associations maximizes the impact of safety improvement plans.
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References
Carver, N., & Hipskind, J. E. (2019). Medical Error. StatPearls Publishing.
FitzHenry, F., et al. (2020). Prevalence and risk factors for opioid-induced constipation in an
older national Veteran cohort. Pain Research and Management, 2020.
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McDermott, O., et al. (2022). Lean Six Sigma in healthcare: A systematic literature review on
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motivations and benefits. Processes, 10(10).
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Melton, K. R., et al. (2019). Smart pumps improve medication safety but increase alert burden in
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neonatal care. BMC Medical Informatics and Decision Making, 19(1).
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Samsiah, A., et al. (2020). Knowledge, perceived barriers and facilitators of medication error
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reporting: a quantitative survey in Malaysian primary care clinics. International Journal of
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Clinical Pharmacy, 42(4).
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Schroers, G., et al. (2020). Nurses’ perceived causes of medication administration errors: A
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qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety,
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47(1).
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Ulrich, B., et al. (2022). National Nurse Work Environments – October 2021: A Status Report.
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Critical Care Nurse, 42(5).

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Visvalingam, P. A. A., et al. (2023). A systematic review of knowledge, attitude, practice and the
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associated factors of medication error among registered nurses. IJFMR – International Journal
for Multidisciplinary Research, 5(4).
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Wondmieneh, A., et al. (2020). Medication administration errors and contributing factors among
nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing,
19(4).
Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting
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m

and proposes evidence-based strategies to improve patient safety.

Analysis of the Root Cause

experience, interruptions during administration, communication inefficiencies, lack of

Application of Evidence-Based Strategies

reduction. Implementing Barcode Medication Administration (BCMA) systems and Smart

for addressing errors and enhancing patient safety.

multi-solution strategies. Establishing a blame-free culture facilitates timely interventions.

Effective communication and collaboration between healthcare professionals positively impact

minimizing errors in hospitals.

Optimal utilization of organizational resources is essential for maximum impact. Hospitals

practices, ultimately reducing adverse events.

like Nursing Associations maximizes the impact of safety improvement plans.

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

older national Veteran cohort. Pain Research and Management, 2020.

Critical Care Nurse, 42(5).

for Multidisciplinary Research, 5(4).

system. Nursing Open.

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