Essay NURS FBX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan TS

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

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

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

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

Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis

     In the robust field of healthcare, patient safety is the number one goal for the success of a healthcare organization. Root cause analysis is a systemic approach through which staff can learn from patient safety incidents such as falls, medication errors etc., and use this knowledge to improve patient care (Haxby , E., & Shuldham , C, 2018).  Healthcare organizations implement root cause analysis following an incident in order to find what happened, how and why , lessons learned, and how to prevent the incidents from reoccurring. The duty to do no harm to patient and implementing a root cause analysis will improve patient outcomes and drastically decrease the rate of errors in healthcare. This root cause analysis will be examining the medication error that occurred during a period when I was managing a 32-bed sub-acute rehab unit. This paper will provide information on what occurred and the changes that needed to be made to reduce such incident.

Analysis of the Root Cause

     On a busy day, the LPN was working her normal 7-3 shift on the rehab unit. This shift is the busiest unit as it is the rehab unit, and every patient has to be up and out of bed so that they can participate in therapy. Med pass typically starts around eight and so the LPN quickly gathered herself to start the hectic shift. Mid way along doing her med pass she realized that one of her patient’s blood pressure was elevated over the normal limit. She stopped and called the doctor for further order as the patient was not due for BP medication during that time. She proceeded to pass meds to the other patient while she waited for the doctor to return her call. Some time had passed, and the doctor returned the LPN’s call. She stopped to take the phone call and received an order for amlodipine 10 MG times one dose now. She wrote it down on a piece of paper and looked over at me and asked if I could go to the medication back up box and get the medication for her as she was now running behind on her med pass. 

     Once the medication was available to the LPN, she proceeded to give the medication to the patient. Never did I thought to look at the patient’s allergy sticker prior to getting the medication. The LPN took the order so it was assumed that she looked at all those information before taking the order, or so I thought. Once I was settled back at my desk, I decided to take a look at the patient’s chart. To my surprise, the first medication that the patient was allergic to on the allergy sticker was to the drug that the patient received- Amlodipine. The incident had me frozen and I alerted the LPN of my finding. She became frantic and paranoid and so we immediately notified the Director of Nursing (DON) of the incident. We explained the situation to the DON and called the doctor immediately. The doctor gave orders to monitor the patient for any adverse reaction and to continue vital signs for the next hour. The patient was notified and was very upset about what had happened. The patient stated, “this is why I am afraid of coming into these places”. This statement made me feel hopeless and afraid that we may have caused serious harm to someone who we swore to protect and do no harm.

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

     The errors made in this root cause analysis are as follow. To start off, according to the five right of medication administration, nurses must verify that medication is being administered to the right patient, route, time, medication, and right dose. However, according to an article written by Julie-Ann Martyn et el, organizational factors such as workload, staffing, supplies and interruptions can interfere with nursing workflow, leading to difficulty in complying with the five-rights framework ( Julie-Ann Martyn et el, 2019). 

     The second error occurred when the LPN was interrupted during her med pass to take the phone call from the doctor. High workload and frequent interruptions have been identified in adversely impacting patient care, including medication errors (Gilbert and Jeong-ah, 2018).

Working in a fast-paced environment and keeping up with the workload of medication pass created a breakdown in the five rights framework for the nurse. In addition, I the unit manager should have communicated with the LPN regarding the patient’s allergy status prior to dispensing the medication. This too could have prevented the event from occurring. When nurses frequently consult with doctors, pharmacists, patients and families during medication activities, patient medication safety and effective care can be maintained (Wei Lue et al, 2016).

Application of  Evidenced – Based Strategy

With the advance of technology, healthcare facility should utilize electronic medical records in an attempt to decrease such errors from occurring. The use of computerized physician ordering systems including bar-code verification technology to confirm the right person, drug, dose, route and time prior to administration in hospital and aged care facilities has been shown to reduce medication errors at the initial stage ( Gilbert and Jeong-ah, 2018). Utilizing a bar code system would have alerted the nurse that the patient was allergic to the medication administered.

     Addressing interruptions that are faced by nurses on a regular basis can be addressed by implementing a system in which other healthcare professional handle phone calls and other non-urgent  issues during med pass time. This would drastically decrease the distraction and potential risk for errors. Task complexity such as medication administration impacts on cognitive load. Being interrupted during more complex tasks taxes an individual’s processing limits which increases error risk ( Westbrook et al. 2017).

Improvement Plan with Evidence-Based and Best-Practice Strategies

This plan will focus on the issues mentioned – instituting a computerized electronic system using bar code scanning and decreasing interruption during medication administration time utilizing a computerized physician ordering system including bar code technology, decrease medication errors as it allows for verification of the patient using the five rights framework. This has shown to decrease medication  errors in the initial stage ( Gilbert and Jeong-ah, 2018). Utilizing this system would have alerted the nurse of any potential allergy associated with the medication once it was scanned. 

     Another improvement strategy to decrease medication error is to decrease the interruptions that nurses face during medication administration times. To do so, utilizing resources that are available such as unit clerks and managers to take care of issues such as phone calls from the doctor, transcribing orders ,and retrieving medication will assist in the reduction of medication errors.


     A root cause analysis is used by healthcare organization to identify the root cause of a problem or issues and  identify how to prevent them from reoccurring. Nurses are at the forefront when administering medications to patients and must be keen to follow the framework that has been set forth for them. This framework includes following the five rights of medication administration in order to decrease errors such as the one mentioned in the scenario. Keeping a continual dialogue among healthcare professional about the patients we take care of can be the difference between life and death. Utilizing evidenced based approach strategy such as computerized physician ordering system, utilizing bar code scanning, and delegating tasks to other staff can also decrease the workload on nurses which can lead to medication errors.


Gilbert, J., & Jeong-ah, K. (2018). To err is human: Medication patient safety in aged care, a case study. Quality in Ageing and Older Adults, 19(2), 126-134. doi:

Haxby , E., & Shuldham , C. (2018). How to undertake a root cause analysis investigation to improve patient safety. Nursing Standard (2014+), 32(20), 41.

Julie-Anne Martyn, Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviours beyond the five-rights. Nurse Education in Practice, 37, 109-114.

Wei Liu Phd, RN, Marie Gerdtz PHD, RN, Elizabeth Manias PHD, RN. (2016). Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

Westbrook, J.I., Raban, M., Walter, S.R. and Douglas, H. (2018), “Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study”, BMJ Quality and Safe

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