Root-Cause Analysis and Safety Improvement Plan Paper

Root-Cause Analysis and Safety Improvement Plan Paper

Root-Cause Analysis and Safety Improvement Plan Paper

A root-cause analysis (RCA) refers to the definition, understanding, and problem-solving process. It compiles various problem-solving methods to establish the actual cause of quality or non-compliance issues. RCA is grounded on the opinion that it is better to handle the causes of a problem than to manage the immediate symptoms. This is because analyzing the causes of a problem identifies a definitive solution, which prevents it from recurring in the future (Martin-Delgado et al., 2020). An RCA of medication administration errors (MAEs) was carried out in an inpatient medical-surgical unit. The purpose of this paper is to analyze the RCA in MAEs, apply evidence-based and best practice interventions to address MAEs, and present a safety improvement plan.


Root-Cause Analysis of MAEs in the Medical-surgical Unit

MAEs are the identified problem in the medical-surgical unit. They occur in various ways, including wrong patient, wrong drug, wrong dose, wrong route, wrong time, omission of doses, failure to document, and technical errors. Generally, MAEs are considered a failure in observing one of the five rights of medication administration: right patient, medication, dose, time, and route (Schroers et al., 2021). MAEs in the unit have been associated with adverse health outcomes, prolonged patient stay, increased morbidity rates, and healthcare costs. Besides, they reduce patient satisfaction and increase legal cases when patients sue health providers and the facility for perpetrating medication errors that negatively impact their health and quality of life (Schroers et al., 2021).

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An RTA was carried out on 15 cases of reported MAEs that occurred in the medical-surgical unit over three subsequent months. The RTA was carried out by a team of four: the nurse in-charge of the unit, a quality improvement expert, a registered nurse from the unit, and a physician. Besides, the reported MAEs occurred in the form of the wrong patient, wrong drug, wrong dose, and wrong route of administration. Although no mortalities were associated with the MAEs, adverse drug effects, allergic reactions, prolonged patient stays, and increased healthcare costs were documented.

The causes of the MAEs were grouped into three: Knowledge-based factors, Contextual factors, and Personal factors. The RTA findings revealed that 10% of the nurses, mostly new graduate nurses, reported that the MAEs occurred due to knowledge-based factors. They include inadequate knowledge of medications and drug administration protocol, inadequate skills, dose miscalculations, and inadequate knowledge and skills to use drug administration technology like the electronic infusion pump. In addition, 95% of the nurses reported that contextual factors contributed to the MAEs.

The reported contextual factors included understaffing, heavy workloads, lack of time, work-related pressure, interruptions and distractions, language barriers, lack of supervision and support, and lack of training. All nurses reported that they were understaffed, overworked, and lacked sufficient time to attend to a patient when administering treatment adequately. This creates a lot of work pressure, creating room for numerous MAEs as the nurses do not concentrate on the drug and dosage they administer to patients (Schroers et al., 2021). Furthermore, the nurses reported being physically exhausted, primarily due to working long shifts and not taking adequate breaks or lunch.

New graduate nurses expressed concern over the lack of supervision and support from their supervisors, which increases work pressure causing mental distraction, and MAEs. Besides, 18% of the new grad nurses reported that they were not oriented on medication administration, which contributed to poor decision-making when administering medications and medication errors. Interruptions and distractions during drug administration were reported by 90% of the nurses. In the reported MAE cases, the nurses stated that they got interrupted when administering medication by other patients or their supervisors and were forced to do another task and, as a result, gave a drug to the wrong patient or administered the wrong drug or dose.

Personal factors were also identified in 40% of the MAE cases, including negligence, psychological stress, lack of confidence in approaching physicians to clarify an order, inattention when administering medication, tendency to make assumptions, and intentional deviations from protocols. Complacency was a major factor, with 75% of the nurses reporting that they tend to make assumptions mainly related to the nurses’ second-check of medication (Schroers et al., 2021). Besides, nurses admitted to making assumptions about the prescribed medications when the written prescription was not clear rather than consulting with the prescribing clinician resulting in the administration of the wrong dose and route. Furthermore, fatigue and physical exhaustion were also reported as personal factors causing MAEs by the nurses.

Application of Evidence-Based Strategies to Reduce MAEs

Various evidence-based strategies have been proposed to reduce MAEs, including low-tech and high-tech approaches. Low-tech solutions include standardized communication whereby health system communication standards are applied to ensure the right medication administration. This also includes using standard abbreviations and numerical conventions in drug labeling (MacDowell et al., 2021). The second strategy is optimizing the nursing workflow to reduce MAEs caused by distractions during the drug administration process. Reducing interruptions during drug administration and creating safety checks through standardized workflows are some of the evidence-based strategies to promote safe drug administration. Organizations can focus on high-risk agents, which have a higher chance of causing patient harm if involved in an administration error (MacDowell et al., 2021). In addition, strategies such as standardized labeling, clear storage of drugs, and using clinical decision support are utilized to promote correct drug selection and administration.

High-tech strategies to address MAEs include smart infusion pumps and barcode medication administration (BCMA) technology. Smart pumps come with many safety advantages. There has been an increased use of smart infusion pumps or infusion pumps with incorporated Dose Error Reduction Software (DERS) (MacDowell et al., 2021). Besides, technological advances provide for smart pump interoperability with the electronic health record (EHR), enabling the smart infusion pump screen to be entered with data from the EHR. Furthermore, the BCMA technology decreases MAEs through barcode labeling of patients, drugs, and health records to automatically link up the right dose of the right drug to the right client at the right time (Naidu & Alicia, 2019).

Evidence-Based Safety Improvement Plan for Safe Medication Administration

The safety improvement plan for safe drug administration will include incorporating BCMA technology and patient education. BCMA technology will seek to lower medication errors in the inpatient setting, while patient education will reduce medication errors at home. BCMA technology involves barcode labeling of patients, drugs, and health. The aim of incorporating BCMA is to ensure that patients are administered the correct drug at the correct time by electronically confirming and documenting the prescribed drugs (Naidu & Alicia, 2019). The data encoded in barcodes will allow for the comparison of the drug being administered with what was prescribed for the patient. Therefore, it will ensure that the five rights of drug administration are observed.

Every medication in the hospital will be labeled with a unique barcode. In addition, each patient’s barcode will have all the crucial health and medication information. When a patient prescription is ordered, it will be transmitted electronically to the pharmacy and keyed into the computer system by the pharmacist (Naidu & Alicia, 2019). The pharmacist will then dispense the bar-coded medication dose to the inpatient unit. During drug administration, nurses will use a barcode reader to scan the barcodes on their staff identification badge, the patient’s wristband, and the medication (Hong et al., 2021). If the system fails to match the medication to be administered with the prescription order in the system, it will alert the nurse.  

Patient education will aim at mitigating medication errors that occur at home. It is essential for health care providers to utilize clear communication strategies and regularly educate patients, particularly when their medication plans are modified. Patient education is part of the safety improvement plan because it is a fundamental component of drug management, especially with high-risk medications such as insulin, opioids, and anticoagulants (Kusch et al., 2018). Patients will be educated routinely about their medications to ensure they understand the drugs’ indication, intended outcomes, and symptoms of adverse events. Each patient will be guided through their prescribed, including their color, shape, and packaging. Patients will be recommended to always double-check the capsule/tablet color after a refill (Kusch et al., 2018). Besides, they will be educated that if the prescription was not changed, the tablet color should not either, and they should inform the pharmacists if there are discrepancies.

Existing Organizational Resources That Could Be Leveraged To Improve a Safety Improvement Plan for Safe Medication Administration

Organizational resources that can be leveraged to improve the safety improvement plan include human resources and technological advancements such as Telemedicine and the EHR. The human resource, including nurses, pharmacists, and physicians, can educate patients about their medications and teach them strategies to prevent medication errors at home (Kusch et al., 2018). Besides, the human resource can be encouraged to give evidence-based ideas to enhance the safety improvement plan further. In addition, technological advancements in the organization, such as Telemedicine, can facilitate patient education and follow-up to ensure they are taking the right medications at the correct dosages. The EHR can be used to provide patient data that will be entered into the BCMA database.


RCA helps identify what transpired, establish why the problem occurred, and embark on the necessary improvements and amendments. The purpose of the RTA was to identify the causes of MAEs, which nurses perpetrated in the unit. Factors associated with MAEs in the unit included inadequate knowledge of medications and drug administration protocol, nurse fatigue due to high work overload, insufficient time, distractions, and assumptions. The proposed safety improvement plan will include adopting BCMA technology and providing patient education to minimize medication errors at the hospital and at home.


Hong, J. Y., Ivory, C. H., VanHouten, C. B., Simpson, C. L., & Novak, L. L. (2021). Disappearing expertise in clinical automation: barcode medication administration and nurse autonomy. Journal of the American Medical Informatics Association, 28(2), 232-238.

Kusch, M. K., Haefeli, W. E., & Seidling, H. M. (2018). How to meet patients’ individual needs for drug information – a scoping review. Patient preference and adherence, 12, 2339–2355.

MacDowell, P., Cabri, A., & Davis, M. (2021). Medication administration errors. PSNet.

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review. Medical Principles and practice: international journal of the Kuwait University, Health Science Centre, 29(6), 524–531.

Naidu, M., & Alicia, Y. L. Y. (2019). Impact of barcode medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health, 11(05), 511.

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38-53.


Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
Create a viable, evidence-based safety improvement plan for safe medication administration.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.


For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
Create a feasible, evidence-based safety improvement plan for safe medication administration.
Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

Assessment 2 Example [PDF]. ( I attached this as Template of Root Cause Analysis)
Additional Requirements

Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.

Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to current APA style.

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