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

Root-Cause Analysis and Safety Improvement Plan

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

A root cause analysis (RCA) is a process for identifying the causal factors underlying variations in performance (Singh, 2021). RCAs are used across various industries when an issue is detected that needs to be remedied. For this paper, I will be evaluating a medication error (ME) that occurred in the emergency department that I work in and exploring how we can prevent them in the future. Since the beginning of this year, 2021, three adverse drug events (ADE) have resulted in near sentinel events. Thankfully, the error was caught and remedied in each instance, but this prompted immediate action by management that has not left the registered nurses (RN) happy.

Analysis of the Root Cause

In our current climate of nursing shortages during the COVID pandemic, there are a lot of seasonal or travel nurses that have arrived at our facility to assist with the patient load. It is common for every healthcare facility to have its own set of protocols, and it is no different from ours. However, due to the lack of adequate training time, three ADEs were reported within the last sixty days, all committed by travel nurses. These ADEs do not necessarily stem from incompetence but rather from a lack of understanding of the protocols used in our ED.

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

At our ED, we can use IV flow regulators to administer certain IV fluids when there are no digital pumps immediately available. These flow regulators are reserved for ordinarily safe fluids such as normal saline and lactated ringers. Since the beginning of the year, we have had three separate ADEs, all stemming from using these flow regulators. A traveler used the flow regulator to administer fentanyl in the first case. In the second, it was propofol, and in the third, insulin. Accordingly, the three near sentinel events faced were respiratory arrest, hypovolemic shock, and hypoglycemic shock.

The immediate response by upper management was to remove these flow regulators from our unit entirely. This decision angered staff RNs who have been using them for years and created a rift between staff and travelers. The sudden increased need for IV pumps led to a situation where RNs walked into random patient rooms and took pumps if they saw one unused without inquiry. These actions led to a petition calling for the removal of travel RNs in exchange for the return of flow regulators. Amid this problem, the Omicron variant caused an increase in patient numbers while displeased travelers started quitting.

In tackling the ADEs, our administration did not conduct a thorough analysis of the root cause of the problem. Instead, they reacted to the situation by removing the flow regulators that were extremely helpful when speed was of the essence. The apparent conditions that led to these MEs are a lack of communication, inadequate training, and unclear protocols. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety, known as the ‘five rights’ or ‘five R’s’ of medication administration (Hanson, 2021). However, these ADEs occurred due to missed protocols.

There should have been a clear explanation of the specific protocols of when and when not to use flow regulators during orientation. Additionally, management should have added checklists to the facility website regarding the use of flow regulators. There was a communication breakdown in addressing the issue, which led to widespread dissatisfaction and finger-pointing. Instead of abruptly removing the tool, there should have been better education on safely using the device during huddles and travel nurse orientation. These steps could have helped solve the problem without an escalation if management had performed an RCA.

Application of Evidence-Based Strategies

One of the most tried and tested methods for reducing medication errors is through proper education. As seen at our facility, one leading cause of MEs that appears in many RCAs is deficiencies in education, training, orientation, and experience (Rodziewicz, T. et al., 2022). By quickly adding a brief section regarding the use of flow regulators into an orientation module, travel nurses would be more equipped to understand when and how to use these devices. This solution should not be challenging to implement as there are already modules that each travel nurse must complete before starting on the floor.

Another issue that led to these ADEs is inadequate staffing and poor supervision (Rodziewicz, T. et al., 2022). Due to the widespread staff RN shortage currently prevalent across hospital systems nationwide, there is a lack of oversight and guidance provided to the new travel nurses. Hiring or designating a resource nurse would be a welcome solution in this instance. Having a resource on the floor whose sole job is to educate and monitor for safety hazards would immensely improve patient safety and reduce ADEs such as these. The charge nurse can act as a resource but may not always be available when needed.

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

However, the biggest failure in our management’s response happened when they decided to remove the flow regulator altogether with no prior conversation, notice, or planning. Having a disjointed system with no problem-solving ability (Rodziewicz, T. et al., 2022) is another commonly identified issue that surfaces when conducting an RCA. Instead of solving a problem, the response from management created a hostile environment that pitted staff against travelers, which led to less-than-optimal working conditions for everyone involved.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Management can take the following steps to improve patient safety and avoid ADEs due to the use of flow regulators:

  • Create a team-based approach that gets everyone on the floor involved in looking out for each other and coming up with solutions to prevent ADEs. 
    • It is important to recognize the invaluable role of all interprofessional healthcare team members in preventing medical error and their role in identifying strategies and solutions in reducing the burden of medical error on the healthcare system (Singh, 2021).
  • Employ a culture of open communication between travelers, staff, and leadership.
    • Communication within the team and with leadership is critical to maintaining organizational structure (Singh, 2021).
  • Use the ADEs as an opportunity to train travelers and existing staff on the safety concerns associated with using flow regulators.
    • Errors represent an opportunity for constructive changes and improved education in health care delivery (Singh, 2021).

With the implementation of these changes, not only will ADEs related to the use of flow regulators be reduced, but better communication will lead to a stronger team. Open lines of communication with management will improve interprofessional collaboration and increase teaching opportunities. The immediate response to these events should have been a detailed email regarding the use of flow regulators. A required class on the use of the devices should be established with multiple opportunities to attend before RNs can be signed off to use these devices. Management can quickly implement all of these changes within a two-week window.

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

Existing Organizational Resources

Currently, our system has a resource library that is easily accessible through the intranet on the unit. Adding clear protocols regarding the use of flow regulators to this list of resources should be an easy implementation. Once the resources are updated, all staff should be notified on how to find the information. Manufacturer recommendations and instructional guides should be made available. Additionally, if an ADE does occur, all staff should be trained on antidotes, reversal agents, and immediate interventions to reduce the damage.


MEs and ADEs are events that will continue to occur from time to time. However, training staff to participate in error recognition and medication safety (Singh, 2021) can reduce the frequency at which they happen. In the specific case of flow regulator-related medication errors, adequate training, guidance, and accountability can lead to zero occurrences. Ultimately, this is the goal that we should strive to attain as a team.


Singh G, Patel RH, Boster J. Root Cause Analysis and Medical Error Prevention. [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Hanson A, Haddad LM. Nursing Rights of Medication Administration. [Updated 2021 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical Error Reduction and Prevention. In StatPearls. StatPearls Publishing.

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