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

NURS FPX 4020 Assessment 2

Capella University
Dr. Lisa Newton
May 2023

Root-Cause Analysis and Safety Improvement Plan

Root-cause assessment or analysis is an essential design for unfolding the causes behind medication mistakes and adopting measures for the future prevention (Singh et al., 2021). These mistakes have lethal results which affect patient’s well-being and healthcare. This assessment aims at evaluating the root causes of medication mistakes and devising evidence-based practices to avoid adverse incidents. Moreover, it determines the available institutional resources to support the execution of the approaches.

Root Causes of Medication

Errors in Healthcare Delivery
Medication mistakes during drug management can have immense patient safety problems. These are emergency situations which need prompt interrogation and handling. Some root causes associated with this are weak communication, human errors, design issues and structured problems (Tariq & Scherbak, 2023).
The root cause evaluation of medication mistakes incident of a 50-year-old patient shows some significant contributing factors. First factor is weak communication among healthcare workers for reading patient’s allergies, medical and medication history. Nurse responsible for medication administration did not review the patient’s medical history properly which had important information about medication history and allergy.  Next factor is lack of standard procedure for medication management which also results in medication mistakes as healthcare workers do not comply with the standard guidelines or protocols. Culture of a healthcare organization may also contribute to the medication error because patient’s safety and quality enhancement is not focused in some healthcare cultures. The interrogation of medication error revealed that insufficient training and education of nurses about patient’s safety and medication management is also a significant factor.
To avoid such events in future, the root cause evaluation suggests the need of executing standard medication management procedures, strengthened communication among healthcare workers, highlighting the importance of patient’s safety in healthcare organization’s particular culture and educate the healthcare staff on medication administration.
Factors Contributing to Safety Issues
There are many factors in a hospital’s setting which result in a patient’s safety problems. These factors are human errors such as lack of focus, exhaustion, and system errors i.e., failed equipment or insufficient guidelines.

● Factors related to human errors are inappropriate staffing, inadequate training, exhaustion, stress, depression and lack of focus which can cause medication mistakes (Kim et al., 2022). For example, nurses who are facing extreme workloads due to increased patient flux may become exhausted and fatigued which leads to wrong medication administration.
● Weak communication is also a significant factor which leads to medication mistakes (Tiwary et al., 2019). Confusing medication guidelines from doctors or mishandling during the prescription delivery among healthcare workers can cause medication errors or dosage mistakes. 
● Design issues i.e., inappropriate naming or wrong storage can lead to medication mistakes (Mutair et al., 2021). For example, if the labelling on medicine is incorrect the nurse can give wrong medicines to a patient.
● Process problems in a healthcare institute i.e., insufficient accessibility of the electronic health records (EHR) or medication databases can cause medication mistakes. For instance, if there is insufficient information available about the latest medication, they can administer the wrong medicine and dose to the patient.
Execution of Evidence-Based Strategies
For handling the medication mistakes which occurred in this given plot, following are the evidence-based practices and best approaches which can be executed:
● Medication Reconciliation: In this approach, discrepancies such as drug reactions or allergies are identified by comparing the patient’s medication sequence with their current medication list. It can help to decrease the medication mistakes occurring during hospitalization, shifting and discharge (Elbeddini et al., 2021).  Nurses dealing with medication administration should have the patient’s medication data and thoroughly investigate before giving any medicine.
● Scanning and Barcoding Technology: It can decrease the probability of medication mistakes by digitally validating the patient’s individual barcode and medicine tag with medication sequence (Chou et al., 2019). This advanced technology can assist to avoid medication mistakes caused by communication barriers or human factors by provision of digital records of administered medicine.
● Training and Education: There should be proper education and training about medication management for nurses and healthcare workers. The training should teach skills on recognition and handling of medicine reactions and allergies.
● Electronic Health Records (EHR): EHR can help to reduce medication mistakes by provision of latest and updated data on patient’s clinical history, medications and allergies (Upadhyay & Hu, 2022). Healthcare workers should have easy access to the EHR system for valid and timely transfer of medication data.
How Strategies will Address Safety Issues?
For handling the medication error event for a 50-year-old male patient, healthcare organizations will execute a set of evidence-based approaches. These approaches consist of in-depth medication reconciliation design to guarantee exact medication management. By using Computerized Physician Order Entry (CPOE), communication mistakes can be reduced. For validation of medication administration,the barcode or scanning technology is an effective approach. By provision of the latest education and training skills to healthcare workers medication errors can be reduced. These approaches will ensure patient’s safety, reduce medication mistakes and avoid future adverse events.

NURS FPX 4020 Assessment 2

Thus, it is the key responsibility of a healthcare organization to guarantee patient’s safety and well-being by executing best evidence-based practices. Use of technological tools, strengthened communication and provision of staff training can reduce the probability of medication mistakes and improve the patient’s health results. By continuously assessing and enhancing the medication management processes, healthcare organizations can sustain safety culture and work on providing elite quality care to patients.
Enhancement Plan with Evidence-Based and Best-Practice Strategies
To reduce medication mistakes and increase patient’s safety in a hospital setting, establishment of a multi-professional team including nurses, doctors and physicians is important for thorough planning (Taberna, 2020). This interdisciplinary team should define some realistic objectives and evaluate the circumstances to attain them. Healthcare workers should be regularly educated and trained through case studies and skill-based training on medication management and safe medical practices. Furthermore, healthcare workers should be updated and professionally progressed by workshops, short courses and conferences with best current medical practices (Mlambo et al., 2021).
An efficient approach for decreasing medication mistakes is implementation of BCMA technology for reduction of nurses’ work burden (Mulac et al., 2021). Moreover, to reduce the immense work burden on healthcare workers, hospitals can employ more nursing staff. By effective execution of these enhancement strategies will enhance patient’s healthcare quality and decrease patient’s mortality rate.
Establishment of policy regulations and laws for improvement of patient’s safety is important. Every healthcare worker and staff member should comply with these policy frameworks to avoid medication mistakes. Healthcare organizations can enhance a patient’s well-being and decrease the probability of medication mistakes by execution of these approaches.
Existing Organizational Resources
Sufficient organizational resources are important for successful execution of safety enhancement plans e.g., safe medication management. These organizational resources are proper staffing, time, work and financial management. Budget allocation is important for the progress of any approach. Pre-budgeting should be completed while considering every cost and planning team should have an economics expert.
Appropriate time management is extremely paramount for successful execution of the plan (Barrot et al., 2021). To ensure reliability of the plan, work burden should be evenly distributed among the group members. Shifting the responsibilities to team members will reduce the workload on healthcare workers and concentrate on improved patient’s well-being. Training and employing new staff members is an expensive and time-consuming process. Thus, existing workers should be used for execution and quality of the approach to avoid time and economical losses.
Using the current organizational resources can significantly affect the execution of the safety enhancement design. Appropriate budget allocation and work burden distribution can decrease the load on healthcare workers and enhance patient’s well-being. Execution of these approaches assist in reducing medication mistakes and improve patient’s care quality and safety in a healthcare institute.


Composing and executing the safety enhancement design for medication management needs inter-professional team strategy, adequate training and education, technology execution i.e., BCMA and appropriate use of organizational resources like budgeting, time and workload management. By giving importance to these approaches and resources according to their productivities, hospitals can decrease medication mistakes, enhance patient’s health outcomes and safety and improve the care quality.


Barrot, J. S., Llenares, I. I., & del Rosario, L. S. (2021). Students’ online learning challenges during the pandemic and how they cope with them: The case of the Philippines. Education and Information Technologies, 26(7321–7338).
Chou, S.-S., Chen, Y.-J., Shen, Y.-T., Yen, H.-F., & Kuo, S.-C. (2019). Implementation and Effectiveness of a Bar Code–Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study. JMIR Medical Informatics, 7(3), e14192.
Elbeddini, A., Almasalkhi, S., Prabaharan, T., Tran, C., Gazarin, M., & Elshahawi, A. (2021). Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources. Journal of Pharmaceutical Policy and Practice, 14(1).
Kim, J., Yu, M., & Hyun, S. S. (2022). Study on Factors That Influence Human Errors: Focused on Cabin Crew. International Journal of Environmental Research and Public Health, 19(9), 5696.
Mlambo, M., Silén, C., & McGrath, C. (2021). Lifelong Learning and Nurses’ Continuing Professional development, a Metasynthesis of the Literature. BMC Nursing, 20(62), 1–13.
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.
Singh, G., Patel, R. H., & Boster, J. (2021). Root cause analysis and medical error prevention. PubMed; StatPearls Publishing.
Taberna, M. (2020). The Multidisciplinary Team (MDT) Approach and Quality of Care. Frontiers in Oncology, 10(85).
Tariq, R. A., & Scherbak, Y. (2023, February 26). 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).
Upadhyay, S., & Hu, H. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians’ lived experiences. Health Services Insights, 15, 1–7.

NURS FPX 4020 Assessment 2

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