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Capella 4020 Assessment 2

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    Capella 4020 Assessment 2

    Capella 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

    Student Name

    Capella University

    NURS-FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name


    Root-Cause Analysis and Safety Improvement Plan

    Numerous cases of sentinel events in healthcare settings have been attributed to medical errors, such as wrong-site surgeries, postoperative complications, and medication administration mistakes. Root cause analysis (RCA) is a valuable tool used to identify the root causes and factors contributing to these incidents. RCA can be applied in healthcare settings to effectively improve patient safety by identifying causal factors and proposing an action plan to mitigate risks. In particular, medication administration errors are a significant concern, according to a systematic review published in 2020, study showed that Adverse Drug Reactions (ADRs) accounted for approximately 3.5% of hospital admission and cause of ~ 197,000 mortalities every year (Khalil & Huang, 2020).

    Mortality rates related to medication errors have been reported in several hospitals and clinics in the USA. This paper will examine RCA of adverse events related to medication administration errors and discuss evidence-based practices to improve patient safety.The document will also include a thorough plan for safety improvement that makes use of organisational assets already in place to solve patient safety issues. To achieve this, healthcare professionals, including nurses, must work collaboratively with the relevant stakeholders to develop and implement effective safety strategies.

    Root Cause Analysis of Errors in Medication Administration

    Medication errors can arise from various sources, such as patients, medical personnel, and nurses. These errors can result from several medication-related risks, which include the number of medications taken by patients, older patient age, incorrect prescriptions, the presence of multiple comorbidities, excessive use of medications, the administration of anticoagulants, and drug interactions, as revealed by several studies (Di Simone et al., 2019).

    Case Study

    An investigation was conducted into a medication administration error at a primary clinic. The error resulted in severe sedation of a 10-year-old boy due to an incorrect dosage of cetirizine, an over-the-counter drug used to treat rhinitis. In a community clinic with a primary care physician, an associate practitioner, and among some nursing staff, the case was discussed. The patient’s mother brought the boy to the clinic with flu symptoms, and the assistant physician prescribed cetirizine in the absence of the GP.

    The mother bought the medication from a pharmacy two days later and reported to the clinic that her son was feeling sleepy and lethargic all the time. The physician and nurses dismissed the mother’s concerns and attributed the side effects to anti-allergic medications. The mother sought a second opinion, which revealed that the prescription dose was too high for a child of the patient’s age. The recommended dose for a 10-year-old is 5mg, while the prescription was for 10mg. The root cause analysis revealed that the staff’s negligence and lack of attention to detail and cross-checking were responsible for the error.

    Root Causes Contributed to Case Study:

      After conducting a root cause analysis of the patient safety issue in the case study of the 10-year-old boy pertaining to medication administration, several contributing factors were identified.

    First, it was found that the patient’s prescriptions had been typed incorrectly; they should have said 5 mg twice daily, not 10 milligramme (mg). This mistake in the prescription could be due to a lack of double-checking and verification processes for prescriptions.

    Secondly, the assistant physician and nurses failed to crosscheck the physician’s prescribed dose, leading to the medication error going unnoticed. The lack of communication and teamwork among the clinical staff could have contributed to this error.

    Thirdly, when the mother contacted back with concerns of sedation and drowsiness, the clinical staff did not recheck the drug dose, which was a missed opportunity to detect the medication error and prevent the harm caused to the patient.

    Additionally, lack of communication is a major concern in clinical settings, and the interpersonal phenomenon was missing in this community center, leading to this avoidable error. Furthermore, the absence of documentation of records in a digital or computerized system could have played a role in the medication error, making it difficult to track and monitor medication administration (Bedolla, 2021).

    Particularly following hospital discharge, prescription mistakes are frequent in primary care settings and are a contributing factor in ADR. After being released from the hospital, MEs were common among adult and older patients, with a 50% frequency. Moreover, ADEs affect about 20% of elderly patients, including the use of antibiotics, antiallergic, antidiabetic, and some analgesics (painkillers) (Sahilu et al., 2020).

    Evidence-Based and Best-Practice Strategies to Reduce Medication Errors

    To address the safety issue identified in the medication administration of the 10-year-old boy, evidence-based and best-practice strategies can be applied to Reduce Drug Prescription Errors. Health providers should be very careful when administering over-the-counter medications and read the exact dosage to the patient or attendants in the facility to make sure it follows their records. To verify the medication and its proper dosage, use a model swiss cheese style. The “Swiss Cheese Model” is a risk management approach used to visualize how multiple layers of defense can protect against errors and failures.

    In this model, each layer of defense is represented by a slice of Swiss cheese, with the holes representing potential weaknesses or gaps in the system. When multiple layers of defense are in place, the holes in one slice of cheese are covered by the next slice, creating a more robust system that is less likely to fail. However, if a hole in one slice of cheese aligns with a hole in another slice, it creates a pathway for an error or failure to occur. The Swiss Cheese Model is often used in healthcare and other high-risk industries to identify potential weaknesses in systems and processes and to develop strategies to improve patient safety (Teoh et al., 2022).

    One approach is to use computerized physician order entry (CPOE) systems to prevent medication errors. A study by Bates et al. (2018) found that implementing a CPOE system resulted in a 48% reduction in medication errors, and a 12.5% reduction in adverse drug events. These systems provide real-time decision support, alerts for drug interactions, and medication dosing errors. To further reduce drug prescription errors, CPOE systems can be connected with additional systems like barcode medication administration (BCMA) and electronic medication administration record (eMAR) (Adams et al., 2021).

    Studies have shown that medication errors are common in primary health care clinics, and the implementation of these evidence-based strategies can significantly reduce the incidence of medication errors, ensuring patient safety and better clinical outcomes. The use of evidence-based strategies such as CPOE, medication reconciliation, clinical decision support systems, and education and training interventions can help address the safety issue identified (Rodziewicz & Hipskind, 2020).

    Evidence-Based Safety Improvement Plan for Safe Medication Administration

     Safe medication administration is essential to ensure patient safety and prevent medication-related issues. For proper medicine delivery, accurate recordkeeping, good communication, and personnel cross-checking are deemed essential. Electronic health records (EHR) have been shown to enhance patient safety and prevent medication-related issues in clinical settings.  The SIP should put a strong emphasis on interdisciplinary collaboration and proactive behaviour from nurses as well as medical staff. EHRs kept in every healthcare environment ought to be utilized to immediately submit adverse event and prescription mistakes to MedWatch (Ratwani et al., 2018).

    According to studies, the use of EMR-enabled CDSS (Clinical Decision Support Systems) can aid in the reduction of medication prescribing errors. The model works on the principles of electronic medical records (EMR) and their documentation, which requires document review before patient communication to avoid prescribing mistakes (Scott et al., 2018).

    CPOE systems have shown to be effective in reducing prescription medication errors by providing a computer-based interface for ordering medications, rather than relying on paper-based orders. With CPOE systems, physicians enter medication orders electronically, which are then automatically checked for potential errors, such as drug interactions, allergies, and incorrect dosages. The system alerts the physician if an error is detected, allowing them to correct the order before it is submitted. CPOE systems also provide decision support tools, such as drug databases, dose calculators, and drug-drug interaction alerts, which help physicians make more informed decisions when prescribing medications.

    These decision support tools can provide valuable information about the patient’s medical history, current medications, and potential drug interactions, allowing physicians to make more informed decisions and avoid errors. Studies have shown that the use of CPOE systems can significantly reduce medication errors, particularly in hospitals and other healthcare settings. For example, a study published by Gates et al (2019) found that the use of CPOE systems reduced medication errors by 80% in pediatric hospitals.

    A specialist or healthcare worker should be there to stop the delivery of prescription and search for a better strategy while an instant report should be made to upper authorities to guarantee safe medication administration. It has been discovered that collaboration as well as encouragement among teammates are useful in lowering adverse outcomes linked to medicine administration mistakes. To improve collaborative skills, registered nurse leaders and staff must employ a number of educational strategies, such as structured collaboration training (Motycka et al., 2018). Academic and healthcare organizations have focused on evidence-based strategies to reduce medication delivery errors. It has been discovered that a range of tools, concepts, documentary evidence in systems, parameters, and organized instructions can aid the prescriber in deprescribing.

     Large-scale studies were conducted in the U.S. by the National Council of State Boards of Nursing to determine what characteristics were common to nurses who made mistakes with drug administration. The most significant finding was that registered nurses who were punished for mistakes with drug administration were similar to other nurses in terms of age, educational background, and work environment (Hensel & Billings, 2020).

    Organizational Resources that can Improve Safety Improvement Plan

    In community clinical settings, electronic health record (EHR) systems can be utilized to document medication administration accurately. This can help in cross-checking information and prevent medication errors by ensuring the correct drug and dose are prescribed. By leveraging this resource, community clinics can develop evidence-based safety improvement plans. The implementation of CDSS in EHR systems has been shown to be effective in reducing medication errors and improving patient safety. Medication reconciliation software helps to identify and resolve discrepancies in medication orders and patient medication history (Scott et al., 2018; Ratwani et al., 2018).).

    Additionally, training programs for nurses and other medical staff can enhance their knowledge and skills in medication administration and communication, leading to improved patient safety outcomes. Organizations can also leverage quality improvement initiatives and patient safety committees to develop and implement safety improvement plans, monitor medication-related adverse events, and implement evidence-based practices to prevent medication errors.


    The use of CDSS incorporated in EHR systems has demonstrated significant effectiveness in reducing medication errors and enhancing patient safety. Medication reconciliation software is also beneficial in recognizing and addressing discrepancies in medication orders and patient medication history. Moreover, training programs aimed at improving the medication administration and communication skills of nurses and other medical personnel can lead to better patient safety outcomes. Quality improvement initiatives and patient safety committees can also be leveraged by organizations to design and implement safety improvement plans, monitor medication-related adverse events, and implement evidence-based practices to prevent medication errors.


    Adams, K. T., Pruitt, Z., Kazi, S., Hettinger, A. Z., Howe, J. L., Fong, A., & Ratwani, R. M. (2021). Identifying health information technology usability issues contributing to medication errors across medication process stages. Journal of Patient Safety17(8), e988-e994. 

    Bates, D. W., Leape, L. L., & Petrycki, S. (2018). Incidence and preventability of adverse drug events in hospitalized adults. Jama, 277(4), 307-311. 

    Bedolla, S. D. (2021). Preventable Error Reduction Leadership Strategies of Nurse Managers in a Hospital Setting (Doctoral dissertation, Walden University). 

    Di Simone, E., Di Muzio, M., Dionisi, S., Giannetta, N., Di Muzio, F., De Gennaro, L., … & Fabbian, F. (2019). Infodemiological patterns in searching medication errors: relationship with risk management and shift work. Eur Rev Med Pharmacol Sci, 23(12), 5522-5529. 

    Hensel, D., & Billings, D. M. (2020). Strategies to teach the National Council of State Boards of nursing clinical judgment model. Nurse educator45(3), 128-132. 

    Khalil, H., & Huang, C. (2020). Adverse drug reactions in primary care: a scoping review. BMC Health Services Research20(1), 1-13. 

    Capella 4020 Assessment 2

    Motycka, C., Egelund, E. F., Gannon, J., Genuardi, F., Gautam, S., Stittsworth, S., … & Simon, L. (2018). Using interprofessional medication management simulations to impact student attitudes toward teamwork to prevent medication errors. Currents in Pharmacy Teaching and Learning10(7), 982-989. 

    Segal, G., Segev, A., Brom, A., Lifshitz, Y., Wasserstrum, Y., & Zimlichman, E. (2019). Reducing drug prescription errors and adverse drug events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient setting. Journal of the American Medical Informatics Association26(12), 1560-1565. 

    Ratwani, R. M., Savage, E., Will, A., Fong, A., Karavite, D., Muthu, N., … & Rising, J. (2018). Identifying electronic health record usability and safety challenges in pediatric settings. Health affairs37(11), 1752-1759. 

    Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 

    Sahilu, T., Getachew, M., Melaku, T., & Sheleme, T. (2020). Adverse drug events and contributing factors among hospitalized adult patients at Jimma medical center, Southwest Ethiopia: A prospective observational study. Current Therapeutic Research, 93, 100611. 

    Scott, I. A., Pillans, P. I., Barras, M., & Morris, C. (2018). Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. Therapeutic advances in drug safety9(9), 559-573. 

    Teoh, L., McCullough, M. J., & Moses, G. (2022). Preventing medication errors in dental practice: An Australian perspective. Journal of Dentistry, 104086. ttps:// 

    Capella 4020 Assessment 2