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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

Root-Cause Analysis

Root cause analysis (RCA) is an issue and problem analysis methodical process, which is used in identifying potential causes related to adverse events, sentinel, near misses, and conflict in the workplace (Kellogg et al., 2016). The purpose of this paper is to apply RCT to the case study to apply EBP strategies to address sentinel events, develop a safety improvement plan, and identify organizational resources that can aid in improving the safety improvement plans. A case study related to medication error in health care, which led to sentinel events of allergic reaction and blame culture was selected for analysis. The allergic reaction included difficulty in breathing and severe dizziness. In the selected scenario or case study, the team was made up of a staff nurse, a risk manager, a pharmacy technician, and a medication dispenser.  The risk manager was the mediator or the leader of the interdisciplinary team, who has the role of facilitating and directing the RCA process to solve the conflict and find the causes (Kellogg et al., 2016).

Analysis of the Root Cause

In the case study, a patient was admitted to the hospital to get treatment for acute diverticulitis. A prescription order of 50 mg Tramadol hydrochloride for every 6-hour PRN pain was sent to the pharmacist. However, it was not administered for the past 8 hours and the patient was asking for the pain medication. The nurse could not administer the medication as the bar-code scanner was not working. However, the nurse used an internal entry number in the computer to assess whether the correct medication was sent. The entry showed that the medication was 325mg, but the medication package said 50mg. The staff nurse followed the hospital’s guidelines to scan the medication barcode, check the medication in the system, and contacted the pharmacist to report the error. 

The pharmacist informed the nurse that there is one digit difference between Ultracet (325mg) and Ultram (50mg) and asked the nurse to administer the medicine and alleged that she might have typed the number wrong. As a result, the nurse administered the medication as the patient was in pain and this led to difficulty in breathing and dizziness. Later, the nurse checked the patient’s record and found that he was allergic to acetaminophen. After that, treatment was provided to the patient and the nurse logged a medication incident report. However, the pharmacy technician and nurse manager failed to take the medication error responsibility and this resulted in a blame culture. As the nurse detected both the error and the allergic reaction, she was at the center of RCA. 

As the RCA team helps in analyzing the issue and finding the root cause of the problem, it included a risk manager, a full-time RN in the unit, and a full-time pharmacy technician from the pharmacy. The Risk manager helps in identifying different threats to patient safety. The full-time RN will provide expertise on MAP and also explains the process behind barcode medication administration. The pharmacy technician helps in explaining the process behind filling medication dispensing machines (Kellogg et al., 2016). 

What was supposed to occur?

The nurse used a flowchart to analyze whether the patient needs medication or not and checked the med box, reviewed medicine in the system, and reported the medication error. The pharmacist did respond to the issue and highlighted the key difference between the two medications, but he blamed the nurse and ignore the possible medication error and its adverse effects instead of verifying the medicine. This is a violation of the ethics of nursing and medicine (Tariq et al., 2021). Also, the nurse administers the medication despite knowing the error. Instead of just suggesting to the staff nurse that she might have entered the wrong IEN, the technician should have informed the staff nurse to request the correct medicine. Also, the staff nurse could have clearly mentioned that IEN is correct. She should have escalated the issue to the nurse manager instead of administering the medication (Manias, 2018). Also, she did not review the patient’s record as he was allergic to the medicine. 

The issue started at the beginning as the first root cause was when the pharmacist dispatched the wrong medicine with dosage (Tariq et al., 2021). Further, the second root cause was the nurse delayed medication administration even though she was supposed to administer the medication two hours ago. She responded only after the patient complained. These were the human errors, which included ignorance, poor judgment, delay in care, failing to acknowledge mistakes and fulfill basic responsibilities (Korb-Savoldelli et al., 2018). Even though the nurse followed the protocol to report the error, the pharmacist missed the protocol to review the medicine by comparing data from resources such as EHR data, prescription data, dispense report, and medication error reporting system (Risør et al., 2018). This resulted in a blame culture. There were no environmental factors involved. The third root cause was failing to effectively communicate, ignoring the issue, and failing to coordinate to solve the issue. In the hindsight, malfunctioned bar-code reader can also be considered as a root cause for the issue.  

Application of Evidence-Based Strategies 

Korb-Savoldelli et al. (2018) proposed to implement a computerized physician order entry (CPOE) system to decrease prescription and dispensing errors as the system includes information regarding patient history, dosage reports, and drug information. The study highlighted that the CPOE system significantly reduced prescription errors and dispensing errors (Korb-Savoldelli et al., 2018). The second EBP change is to provide quick troubleshooting support and make sure nurses have working bar-code readers to directly report medication errors to pharmacists. Such a system reduced medication errors by 43.5% and annual harm events by 5.4% (Thompson et al., 2018). 

Identity best practices strategies to address the safety issue or sentinel event. 

The third strategy is to implement an automated error reporting system that includes a patient-specific automated medication system (npsAMS) unit, barcode medication administration (BCMA), and a complex automated medication system (cAMS) with the automated dispensing unit to reduce human errors in communication and decision-making. As the process used an integrated system, the errors were reduced from 0.96 to 0.15 (Risør et al., 2018). Koyama et al. (2021) proposed an EBP strategy to double-check medicine through the checklist, implementing hierarchical protocols, and educating interprofessional teams to reduce medication administration errors. The strategy reduced errors as double-checking reduced human errors. Also, recommendations by QSEN and IOM to train health care staff to communicate and collaborate aid in both error prevention and management (Abukhader & Abukhader, 2020). 


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

Improvement Plan with Evidence-Based and Best-Practice Strategies

The action plan is multi-disciplinary and multimodal as it includes different actions for different stakeholders. The first step is to develop a hospital-based protocol and hierarchical response system with a medication error alert system to quickly detect the errors and provide steps taken to report the error along with the responsibilities of different stakeholders (Huckels-Baumgart et al., 2017). This plan aid in solving the first root-cause where the pharmacist sent the wrong product. The outcome of this step is it increases knowledge and competencies along with better communication between the team (Korb-Savoldelli et al., 2018). 

The second step is to educate the health care professionals to predict the medication errors and fulfill the protocol through communication and discussion (Manias, 2018). This includes providing timely care, not administering the drug unless completely sure, and reporting all errors. This step solves the root-cause where the pharmacist accused the nurse of committing an error and the nurse following the pharmacist’s instruction even the system pointed out that the wrong medication was sent (Huckels-Baumgart et al., 2017). The outcome of this step is it creates a safer work culture with specific roles and responsibilities (Kellogg et al., 2016). 

The third step is to implement a single system with prescription order, patient information, automated drug dispensing unit, double-check protocol (Koyama et al., 2021), bar-code-based identification, communication, and error reporting system (Thompson et al., 2018). This provides a centralized system to detect the root cause and aid in preventing delayed care and averse of sentinel events (Risør et al., 2018). This system aid in achieving the outcome of funding and solving all the root-causes as all the systems are integrated into one. 

The action plan will have goals to prevent prescription errors, wrong dosage errors, dispensing and drug administration errors, blame culture, delay in care, and adverse effects. Also, it aims to increase interprofessional collaboration and the effectiveness of the system (Risør et al., 2018). However, the plan takes time as it requires organizational-level change. Developing protocols, educating health care professionals, and assigning roles can take 4 to 6 weeks. Implementing the centralized system will take 12 to 16 months. 

Existing Organizational Resources

Four major existing organizational resources that aid in implementing the plan are health care professionals, IT infrastructure, finances, and leaders and managers to design a plan, implement it and evaluate the outcome (Hammoudi et al., 2017). Also, existing protocols and nurse informatics relating the medication errors help in determining the trend and effectiveness of different outcomes (Manias, 2018).


Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines08(06), 135-147. https://doi.org/10.4236/jbm.2020.86013

Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences32(3), 1038-1046. https://doi.org/10.1111/scs.12546

Huckels-Baumgart, S., Niederberger, M., Manser, T., Meier, C., & Meyer-Massetti, C. (2017). A combined intervention to reduce interruptions during medication preparation and double-checking: a pilot-study evaluating the impact of staff training and safety vests. Journal Of Nursing Management25(7), 539-548. https://doi.org/10.1111/jonm.12491

Kellogg, K., Hettinger, Z., Shah, M., Wears, R., Sellers, C., Squires, M., & Fairbanks, R. (2016). Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Quality & Safety, bmjqs-2016-005991. https://doi.org/10.1136/bmjqs-2016-005991

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022

Koyama, A., Maddox, C., Li, L., Bucknall, T., & Westbrook, J. (2021). Effectiveness of double checking to reduce medication administration errors: a systematic review. BJM Quality & Safety29(7). https://doi.org/http://dx.doi.org/10.1136/bmjqs-2019-009552

Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety17(3), 259-275. https://doi.org/10.1080/14740338.2018.1424830

Risør, B., Lisby, M., & Sørensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. International Journal For Quality In Health Care30(6), 457-465. https://doi.org/10.1093/intqhc/mzy042

Tariq, R., Vashisht, V., Sinha, A., & Scherbak, y. (2021). Medication dispensing errors and prevention. Retrieved 17 March 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519065/.

Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001

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

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