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

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

    Student Name

     University Name

    NURS FPX 4020 Improving Quality of Care and Patient Safety

    Instructor Name


    Root-Cause Analysis and Safety Improvement Plan

    Root-cause analysis (RCA) is a systematic strategy for solving problems and issues that cause significant destruction in any organization. Healthcare organizations use this strategy to resolve various issues, including preventable adverse events such as medication administration errors. The prevailing medication administration errors called for immediate action of RCA to lessen medication administration errors. This paper will highlight the use of RCA in Acadia General Hospital (AGH), where medication administration errors critically impact patient safety. Moreover, the assessment will discuss the root causes of recent medication administration errors in AGH, apply evidence-based practice strategies, and craft a safety improvement plan. Lastly, it will highlight identified existing resources of AGH that could be leveraged to improve safety improvement plans for safe medication administration.

    Analysis of the Root Cause

    Several medication administration errors occurred at AGH, but the incident of medication administration error due to the wrong medication by Jenna instigated the RCA. Jenna was a nurse on duty in the medical ward; on her evening round, she found that one of her patients, Graham, who complained of arthritis pain, required a dose of “Celebrex.” The nurse retrieved the wrong medication, “Celexa,” instead of “Celebrex”  due to lack of attention and being mentally absent during dispensing. Additionally, the question arises if the ward environment was chaotic or if there were distractions that could have contributed to Jenna’s mistake.

    Moreover, she did not double-check the medication before handing it to the patient. Graham took the medication without knowing that it was the wrong medication. It is essential to probe if there was a breakdown in communication between Jenna and Graham or if the patient was adequately informed about the medication he was receiving. The nurse found the mistake when investigating the medication administration chart and immediately reported to the healthcare team to manage Graham’s condition. Fortunately, the patient did not suffer any severe side effects of the anti-depressant agent to stabilize mood.

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

    This error could have been prevented if the nurse exhibited attentive behavior and mindful performance during medication administration. The negligent behavior toward crucial tasks like medication administration was the primary cause of this incident. Moreover, the nurse did not comply with the medication administration protocols and required further education and training on safe medication delivery. The situation calls for evaluating whether communication between the medical staff, particularly in relaying and verifying medication instructions, was effective and transparent. When nurses show inadequate attention and mindfulness attitudes, these errors occur frequently, particularly for sound-alike and look-alikes medications (Schroers et al., 2020). Furthermore, the lack of technology-based medication administration further results in medication errors. The presence of healthcare information technology can alleviate the incidences of these errors. 

    Application of Evidence-Based Strategies

    The literature addresses numerous factors that lead to safety issues during medication administration. One study states that out of 185 nurses, 24 engaged in medication administration errors due to a lack of training on safe medication administration (Wondmieneh et al., 2020). Therefore, healthcare organizations must implement evidence-based strategies. One of these strategies includes training nurses on mindfulness during medication administration procedures. The literature substantiates this strategy, as 73.3% of medication errors are reduced by training nurses on mindfulness and attentive behaviors (Ekkens & Gordon, 2021).

    Another strategy includes integrating barcode medication administration (BCMA) technology to avoid medication administration errors due to wrong medication. The barcode will identify and confirm that the medication administered is correct and matches the one prescribed to the patient. This will result in enhanced patient safety and reduced incidence of medication administration (Mulac et al., 2021). Lastly, developing protocols on medication administration within hospitals can reduce medication administration errors as nurses will be held accountable in case of any violations of those protocols. Nurses will be more focused on implementing the protocols and relevant policies on medication administration due to the vulnerability of losing their jobs, heavy fines, and litigation actions (Vaismoradi et al., 2020).

    Safety Improvement Plan

    Nurse leaders and the hospital administration collaborated to develop a safety improvement plan for AGH. The plan aims to address medication administration errors. It is both realistic and grounded in evidence-based strategies. Specific actions, policies, and processes have been outlined for implementation, complete with goals and timelines.

    Training Nurses on Mindfulness

    The nurse leader will conduct mindfulness and focused medication administration training sessions for three months after developing this plan. This training will teach them the importance of attentive behaviors and mindfulness during the most crucial medication management tasks. Moreover, nurses will learn to avoid interruptions and be mentally present while administering medication to patients. Through this training, nurses will avoid making mistakes due to a lack of focus and attention. The desired outcomes and goals of this training include delivering correct medications to patients with a clear and focused mind and reducing medication errors due to nurses’ negligent behaviors (Ekkens & Gordon, 2021).

    Integration and Implementation of BCMA 

    The hospital will integrate a new technological process to reduce AGH medication errors. The barcode medication administration technology will allow nurses to match the barcode on the medication’s label with that of the patient’s prescribed barcode on the wrist. If the barcodes do not match, nurses will be alerted to the wrong medication, preventing its administration. Moreover, nurses can check which medication is required to administer to a patient related to his health condition, leading to safe medication management. The outcome of this technology will be reduced rates of medication administration errors due to wrong medication. Nurses will deliver the correct and proper medication, enhancing patient safety and reducing harm due to medication administration errors (Mulac et al., 2021). This strategy will require a timeline of six months as it requires financial, material, and human resources. 

    New Policies on Medication Administration

    The AGH will develop new policies on medication administration, such as penalties for violating the medication administration rules on double-checking medication before administration and implementing the five rights of medication rule. Another policy will include job termination on consistent incidents of three medication errors per month. These policies will be developed over one month and will be applied within all departments, and implementation will be done at once. These policies will make nurses more vigilant and extra careful towards medication administration, leading to increased adherence to protocols and fewer chances of medication administration errors (Vaismoradi et al., 2020).

    Existing Organizational Resources

    The existing personnel crucial to the successful implementation of the safe improvement plan encompass the hospital administration, nurse leaders, and frontline nurses. The administration will helm the strategic aspects of the safety improvement plan’s development and oversee its rollout. Their role in allocating resources and endorsing key components of the plan is pivotal. Meanwhile, nurse leaders are critical in bridging the gap between strategic planning and on-the-ground implementation.

    Their duties will extend to orchestrating training sessions, enhancing inter-departmental communication, and ensuring that best practices are followed. As the primary executors, frontline nurses will directly implement the safety protocols and measures outlined in the plan. AGH’s electronic health records (EHR) are a significant asset in terms of infrastructure. This system will be intricately woven into the safety improvement plan, serving multiple roles. It’s primed to enforce medication safety checks by generating patient-specific barcodes on wristbands, aligning with the barcodes on medication labels, and ensuring correct medication administration.

    Furthermore, the EHR system will act as a repository and checker, offering a comprehensive view of patients’ medication histories, pinpointing contraindications, and mitigating the risk of medication duplications. Its analytical capabilities should be prioritized, as periodic analysis of quality improvement data through the EHR will provide insights into medication error patterns, guiding further refinements in the safety plan. For the plan’s full-fledged implementation, specific pivotal resources will be requisitioned. These include barcode machines for each department, relevant labeling materials, technology infrastructure enhancement, and the necessary financial provisions for these acquisitions. Prioritizing these is crucial, as they form the bedrock for many of the plan’s key components. A dedicated budget will be allocated for training, especially in mindfulness during medication administration, to equip nurses adequately.


    The Acadia General Hospital has been encountering medication administration errors. Therefore, the root-cause analysis has been conducted to overcome the emerging issue. The root-cause analysis revealed that the nurse’s negligent behavior led this incident to occur. This called for applying evidence-based strategies, including mindfulness training for nurses, integration of BCMA technology, and policy development. These evidence-based practices are the primary component of the safety improvement plan that the existing personnel will execute: administration, nurse leaders, nurses, and resources like EHR and quality improvement data utilization.


    Ekkens, C. L., & Gordon, P. A. (2021). The mindful path to nursing accuracy. Holistic Nursing Practice, 35(3). 

    Mulac, A., Mathiesen, L., Taxis, K., & 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.

    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). 

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

    Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15.

    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.