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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

    Capella University

    NURS FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name


    Root Cause Analysis and Safety Enhancement Plan

    Root Cause Analysis (RCA) stands as an effective methodology for identifying factors associated with patient safety risks. Given the heightened occurrence of medication administration issues and adverse events within a healthcare organization, patient safety has become a matter of paramount concern. RCA plays a crucial role in mitigating preventable adverse events, enhancing patient safety protocols, and fostering learning and quality improvement in healthcare environments. Medication errors, particularly in administration, rank as the eighth leading cause of death in the USA. Several studies emphasize that Medication Administration Errors (MAEs) significantly contribute to patient safety risks, especially in acute care settings, leading to prolonged hospital stays (Samsiah et al., 2020). This review specifically focuses on scrutinizing the root causes of drug administration errors causing patient safety issues in the diabetic ward. It delves into patient safety issues related to medication administration, highlighting evidence-based safety improvement strategies and organizational interventions.

    Analysis of the Root Cause

    Various factors contribute to being the root cause of medication administration errors in the diabetic ward, as evidenced by Assessment 1. These include inadequate training, deviation from medication administration guidelines, insufficient work experience, interruptions during medication administration, ineffective communication, lack of knowledge, and human factors. Nursing staff with inadequate training are more prone to errors, emphasizing the positive correlation between nursing staff experience and quality of patient care (Ulrich et al., 2022). Communication gaps among healthcare professionals often lead to medication administration errors. Qualitative evaluations indicate a significant lack of medication knowledge among nurses (Schroers et al., 2020). Unavailability of guidelines and deviation from established protocols double the risk of medication errors (Wondmieneh et al., 2020). Minimizing interruptions during medication administration, addressing human factors, and managing stress contribute to error reduction (Brigitta & Dhamanti, 2020).

    Application of Evidence-Based Strategies

    To address obstacles contributing to safety issues related to medication administration errors, evidence-based solutions are imperative to establish a safety culture and enhance nurses’ competence. Training and education of nurses positively impact the reduction of medication administration errors (Yoon & Sohng, 2021). Active involvement of patients, families, and healthcare providers can enhance the accuracy of drug history and prevent adverse events. Adhering to the “five rights” of pharmaceutical administration and utilizing Barcode Medicine Administration (BCMA) systems significantly reduce the likelihood of errors (FitzHenry et al., 2020). Smart infusion pumps with Dose Error Reduction Systems (DERS) and Clinical Decision Support (CDS) Systems provide additional safety precautions during administration.

    Evidence-Based Safety Improvement Plans

    Safety improvement plans aim to reduce errors leading to adverse events, incorporating root cause and error-based multiple-solution strategies. Establishing a blame-free culture, focusing on error causes rather than individuals, encourages reporting and timely interventions (Carver & Hipskind, 2019). Effective communication and collaboration between nurses and physicians positively impact patient care quality (Visvalingam et al., 2023). Technological tools like BCMA and CDSS enhance accurate medication administration. The Lean Six Sigma Plus methodology reduces medication errors by streamlining processes, standardizing protocols, and enhancing patient satisfaction (McDermott et al., 2022).

    Organizational Resources

    Optimal utilization of existing and potential organizational resources is crucial for a comprehensive safety improvement plan. These resources include healthcare staff, technological tools, strategies, and financial resources. Healthcare settings should provide updated knowledge and training through frequent in-service sessions. Investments in advanced tools reduce adverse events during medication administration. Multidisciplinary teams and professional organizations contribute to standardization, best practices, and ongoing education, resulting in a reduction in adverse events.


    The root cause analysis of medication errors in acute care settings is essential for systematically identifying causes and preventing future occurrences that contribute to patient safety issues. Evidence-based approaches are necessary to overcome barriers related to safety issues associated with medication administration errors. The utilization of the Lean Six Sigma approach provides a thorough solution, emphasizing the need for action after the study is concluded. Nursing associations and professional organizations can effectively contribute to maximizing the potential impact of a complete safety improvement plan.


    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.

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

    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.

    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.

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

    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).

    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.