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

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

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

Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis

The root analysis that will be discussed in this paper is about medication administration errors, and their possible causative associated events. The setting of where the error took place is on a medical / surgical unit of a hospital during the first surge of COVID-19. This paper will explain and examine medication errors, and discuss about evidence-based strategies that will help reduce the amount of medication administration errors. This paper will also discuss safety improvement plans centered on the application of current organizational resources to discourse the issue of medication administration errors. 

Analysis of the Root Cause

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

The transpired event occurred on medical surgical acute care setting / floor in a rural hospital. A specific medication that is known to cause adverse effects requires a two nurse witness protocol. This is an evidenced based practice that is known to prevent possible adverse reactions to medication therapy to patients. Unfortunately, even with the best safeguards, possible scenarios can occur where even the best protocol can break down. While providing medication administration to multiple patients requiring controlled substances and monitored therapy, communication breakdown lead to an adverse event. There was no malice intended, but due to complications related to the COVID-19 pandemic, normal safeguards were overlooked. While providing one controlled substance to a patient that required a witness, the nurse who was witnessing the medication took it upon themselves to help with my medication administration. Unbeknownst to them, the second medication they witnessed was for a different patient. The nurse tried to help me by providing that medication to the patient they believed was receiving that therapy, but it was not. The “help” became a hindrance, and a major safety event occurred.  

A close analysis of the event combined with an after action review yielded multiple breakdowns in protocols including but not limited to: electronic safeguards, chain of custody of medications, and environmental factors. The witnessing nurse should never have administered controlled substances to a patient who was not under their care. The nurse had no prior knowledge of the patient which in turn violated the patient medication rights. Furthermore, the nurse witness’s main job is to verify that the patient’s medication rights were verified by the nurse providing the medication therapy, not to provide said medication therapy. The electronic health records requires a single nurse to login in to the patient’s medical record, not two tandemly. This how the double check exists, not two single checks. Lastly, the medication in question had the patient demographics clearly listed on the medication, but due to the electronic nature of the hospital environment and reliance and bar code scanning, the verification did not occur. Unfortunately, the perfect storm of events occurred the resulted in an adverse event to the patient.  

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

Robert Lloyd, Institute for Healthcare Improvement Vice President, describes a specific way to analyze this type of event in a cause and event diagram (Lloyd, 2021). Specifically the “Fish Bone Diagram” is a visual way to use the head of the fish to represent the problem, and the spines as categories leading up to the issue (Lloyd, 2021). The main issue, the nurse not assigned to a patient providing a medication that was not ordered for a specific patient, is very concerning. The identified categories include people, machines or technology, and environment. Personnel not adhered to protocol puts others in danger. Technology that is not used properly or how it was designed regarding safety protocols puts other in danger. An already stressful environment that is exacerbated by a global pandemic creates an even more dangerous environment that affects the people that are working within. These three events are the root cause of this safety event.  

Application of Evidence-Based Strategies 

Protocols are in place to prevent adverse situations like this from happening. Deviating from this protocol, for any reason, can possibly cause an adverse reaction. Dr. David Bates, the Senior Vice President and Chief Innovation Officer of Brigham and Women’s Hospital recognizing that the human condition is inherently connected to making errors at times (Bates, 2021). This is why the witnessing protocol concerning medication administration was created. Regardless of how much we scrutinize ourselves when applying our nursing skills to the fullest to provide the best care to our patients, humans are inherently fallible creatures. However, when applying a peer check protocol, the error rate should decrease. This entire scenario is exactly why we peer check ourselves. When the COVID-19 pandemic originally started, the hospital environment was a very confusing place. Nurses were forgetting the foundational training and trying to help wherever possible. Unfortunately, this event is culmination of human error and complete disregard of safety protocols. Regardless of best intentions and a motivation to help, the result put a patient in danger. Fortunately, this is a reminder of why safety protocols are in place.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Interestingly, there were already strategies in place to prevent situations like this from occurring. Azmoude, Farkhondeh, Ahorr and Kabirian states, “…many health care decisions are still based on traditional practices, assumptions, personal experiences and opinions and individual skills” (2017). Teamwork and nursing are very closely related. We rely on one another to help complete out tasks. Unfortunately, in this pandemic era, we cannot rely on personal experience, assumptions and opinions. There should be increased emphasis on protocol and policies, to prevent adverse situations likes this from occurring.  

Existing Organizational Resources

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

An after action review of this current event showed that a lack of adhering to already in place polices and protocols lead to this situation. Education was provided to the nurse that did not follow the protocol. There was however emphasis that teamwork should be promoted, but not when it does not adhere to facility polices. Furthermore, department heads were alerted that the COVID-19 pandemic had a “two fold pendulum swing” that was increasing collaborative teamwork, but also creating situation where safety protocols were not being followed. Further attention to situations showed that there were other safety events that were related to this type of event. The facility has now instituted mandatory review of internal policies regarding technology, medication administration, restrains, personal protective equipment to name but a few every six months to reinforce these protocols. 


Safety events can and will occur, but will not always be recognized. Identification of these events is imperative to make positive changes, and hopefully prevent them from reoccurring in the future. Unfortunately, this event was an already identified safety concern with protocols in place to prevent. This highlights the critical need for reminders of facility protocols, and why they are in place. As nurses, we have agreed to lifelong education. This does not exclude reviewing why we follow rules.


Azmoude, E., Farkhondeh, F., Ahour, M., & Kabirian, M. (2017). Knowledge, practice and self-efficacy in evidence-based practice among midwives in East Iran. Sultan Qabood University Medical Journal, 17(1), e66-e73

Bates, D. (2021). Why is reducing harm-not just error-important to safe? Institute for Healthcare Improvement. Retrieved from

Lloyd, R. (2021). Cause and effect diagram. Institute for Healthcare Improvement. Retrieved from

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