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


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

Persistent drug administration errors caused by treatment management problems are a safety hazard in the healthcare context that must be addressed. This problem stems from pharmaceutical delivery processes that are inadequately constructed, as well as a failure to follow proper standards and policies while administering treatment. Mayo Clinic’s healthcare system has been plagued with pharmaceutical administration errors in the recent past, with multiple instances of inaccuracy. In some cases, these errors included administering the improper dose, the wrong medicine, and missing doses, which are the most commonly reported medication administration errors in the healthcare environment. Medication administration mistakes are a safety issue, and this paper will examine the fundamental causes of the problem, the use of evidence-based solutions, and a safety improvement strategy with evidence-based and best practices.

Root cause analysis

Poor communication between health care practitioners and patients, drug labels that seem similar, and prescriptions that sound similar are all core causes of medication administration and treatment management mistakes. Many mistakes can be made when providing medicine, such as inappropriate quantities, the wrong time, the wrong substance, incorrect modes of administration, and the exclusion of certain amounts. Misdiagnosis, mistakes in counselling, dosage discrepancies and catastrophic drug distribution were all regular occurrences at the Mayo Clinic (Wen et al., 2019). Other issues included incorrect medication management, ineffective communication and a lack of appropriate patient education. The Mayo Clinic’s return patients noticed this problem and made complaints about the drug delivery problems stated above. The Mayo Clinic’s patients, their families, and the whole community that relied on their services were the primary beneficiaries of this problem. Due to mistakes relating to missing prescriptions, duplicate medications and dose problems in drug interactions that even exacerbated the health of certain patients, the issue had a direct detrimental impact on the patients and their families.

It is important to highlight that the patients’ health deteriorated due to the drug administration mistakes, as well as the incidence of antagonistic pharmaceutical interactions and a longer hospital stay because of this (Suclupe et al., 2020). Further medicine to improve their health was also more expensive as a result of the problem. It is important to note, however, that the care seekers and providers were both affected by the medicine delivery errors that happened accidentally; this caused certain cases of hostile mental and bad expressive impacts on the convoluted providers. Burnout, a lack of focus, poor work conditions, PTSD triggers, sadness, suicidality, and rejection are just some of the adverse effects that patients have experienced as a result of this problem. Patient distrust, civil lawsuits, criminal prosecution, and medical board sanctions are all possibilities for doctors who make drug mistakes. Misdiagnosis and mistreatment of certain patients led to long-term and even fatal consequences for those who were given the improper medication and dosage.

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

To achieve the desired outcome, criteria and dose prescriptions were to be adhered to in the administration of drugs. This would have fixed the problems that occurred when the medications were administered (Asensi-Vicente et al., 2017). Considering the root cause of this problem, it is clear that some procedures were not done and that some patients’ care practises were not administered the prescription as planned. The environmental factors that influenced the issue of medication administration errors included excessive noise levels that impeded communication between patients and caregivers, poor lighting and inappropriate environmental temperature, the principles of the operational environment, and the degree of drug faults that resulted in the medication errors. This includes elements in the environment contaminated by pollutants and severe weather conditions; the existence of some disease-causing microbes; the absence of high-quality health care infrastructure; and low service eminence.

It was the Mayo Clinic’s medical assets and resources, as well as its buildings, employees, and funding, that had a significant impact on the situation. Patients’ and caregivers’ mental tension, loss of inspiration, having a large workload, routine deprivation of communication, and misused patient data housed in the information systems were all variables that led to the medicine administration problems experienced. Listening and paying attention to the doctor’s prescriptions, the communication method, the patient’s emotional awareness, the use of written communication, and speaking in challenging situations were all communication aspects that contributed to the medical administration issue.

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

Use of evidence-based strategy

According to prior research, pharmaceutical delivery errors are frequently attributed to a breakdown in the traditional rights to treatment management. This includes activities such as not treating the proper patient, prescribing the wrong drug, and prescribing it at the wrong time. There has been a connection between these elements and the problem of medication administration safety in the hospital context. Errors in drug administration and treatment are part of a multidisciplinary team that works collaboratively to ensure patient-centred quality care delivery, according to current literature. There is a higher chance of medication mistakes if patients are not properly educated or communicated with before taking their prescription (Rohde & Domm, 2017). Medical administration errors safety can be addressed by identifying and addressing the gaps in care that lead to the incidence of medication administration errors. This issue may be addressed by adopting standardised communication, providing appropriate patient education and increasing nursing workflow to limit the risk of mistakes.

Improvement Plan with Evidence-Based and Best-Practice Strategies

To address the core causes of the medical administration mistake problem, the Mayo Clinic healthcare environment should implement the following practices: arrangements, new processes, new policies, and/or professional development. The Mayo Clinic Health System’s application of standardised communication standards will help ensure that the proper medication is prescribed to patients and caregivers. The same directives also recommend common abbreviations and arithmetical norms (Alrabadi et al., 2021). Patient education in the healthcare context can assist reduce the danger of making mistakes in healing management. If prescription methods are adjusted or altered, all healthcare practitioners must use the correct communication tactics and policies that are usually offered to patients via education programmes.

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

As a result of these new processes, the medical administration’s propensity for mistakes will be reduced. It is not uncommon for distractions to be used during the medicine administration procedure, which increases both the likelihood and severity of medication administration mistakes. Medication administration may be made more efficient by minimising interruptions and organising care checks through regular routines. There will be a need for laws like the Medicines Act of 1968 to help establish legal frameworks for the prescription of medications and the provision of suitable storage and administration of medications, allowing them to be properly classified (Hammoudi et al., 2017). As the legislation that governs the distribution of medicine to patients, this policy is critical. Actions taken to enhance drug administration, eliminate medication mistakes, and ensure that patients receive their medicine at the right time are all aimed at avoiding misinterpretation. This strategy will be put into action over four months, with results being evaluated on a month-by-month basis.

Existing Organizational resources

Mayo Clinic Healthcare workers who are actively involved in excellent development efforts, including as nurses, medical technicians, physicians, and other medical staff, are among those who may assist enhance the execution and outcomes of the plan Materials, employees, finances, and facilities associated with the delivery of high-quality health care services may be necessary for the plan’s success. Consequently, human resources (resources for work), capital (resources for cost), and material commodities are all necessary components of this strategy (material resources).


Errors in prescribing, dispensing, administering, and giving medication are indicative of inexperience in these procedures. Many people in the United States have been harmed by prescription mistakes in the past. The vast majority of medicine administration mistakes may be avoided, though. Improve patient education and standardise communications in the health care context to prevent drug delivery mistakes. In addition, caregivers, patients, and practitioners at the Mayo Clinic are to blame for this safety concern because of inadequate health literacy, lack of patient-provider communication, lack of health understanding, and collective safeguards.


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

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: a focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025

Asensi-Vicente, J., Jiménez-Ruiz, I., & Vizcaya-Moreno, M. F. (2017). Medication Errors Involving Nursing Students. Nurse Educator, 43(5), 1. https://doi.org/10.1097/nne.0000000000000481

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences, 32(3), 1038–1046. https://doi.org/10.1111/scs.12546

Rohde, E., & Domm, E. (2017). Nurses’ clinical reasoning practices that support safe medication administration: An integrative review of the literature. Journal of Clinical Nursing, 27(3-4), e402–e411. https://doi.org/10.1111/jocn.14077

Suclupe, S., Martinez‐Zapata, M. J., Mancebo, J., Font‐Vaquer, A., Castillo‐Masa, A. M., Viñolas, I., Morán, I., & Robleda, G. (2020). Medication errors in prescription and administration in critically ill patients. Journal of Advanced Nursing, 76(5). https://doi.org/10.1111/jan.14322Wen, A., Fu, S., Moon, S., El Wazir, M., Rosenbaum, A., Kaggal, V. C., Liu, S., Sohn, S., Liu, H., & Fan, J. (2019). Desiderata for delivering NLP to accelerate healthcare AI advancement and a Mayo Clinic NLP-as-a-service implementation. Npj Digital Medicine, 2(1). https://doi.org/10.1038/s41746-019-0208-8

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