Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan

Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan


· For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Analyze the elements of a successful quality improvement initiative.

1. Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;

1. Create a viable, evidence-based safety improvement plan for safe medication administration.

. Competency 2: Analyze factors that lead to patient safety risks.

2. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

. Competency 3: Identify organizational interventions to promote patient safety.

3. Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.

. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

4. Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.


For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

. The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.

. The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.


The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the  Root-Cause Analysis and Improvement Plan [DOCX]  template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

. Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.

. Create a feasible, evidence-based safety improvement plan for safe medication administration.

. Identify organizational resources that could be leveraged to improve your plan for safe medication administration.

. Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

Assessment 2 Example [PDF] .

Additional Requirements

. Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.

. Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

. APA formatting: Format references and citations according to current APA style.


Root-cause analysis often refers to a systematic approach aimed at identifying the initial causative agent “root cause” of a given medical problem and possible approaches towards providing an amicable solution to the problem. The root cause analysis can make emphasis on established approaches, used tools, and techniques established to reveal the cause of the problem. Different root analyses often function uniquely towards problem-solving, some of the approaches are more inclined towards identifying true root causes than other approaches, some are more inclined towards general problem-solving techniques while others simply work by offering support to the main process of cause analysis. For instance, an approach based not only on reducing the medical administration errors but finding a solution to address the cause of administration errors.

The root cause analysis of increased medical costs and deaths following medical negligence and errors in medical administration was conducted at a health facility. The paper illustrates and discusses the causes and impact of medication administration errors on patient health and the use of evidence-based strategies towards reducing medical errors and deaths among patients. Equally determining safety improvement plan based on utilization of existing organizational resources to address the challenges of medication administration errors (Dolansky, et al., 2013).

Root cause analysis of medical administration error

Patient safety and care have been the major concern in society and policymaking. The nurses are among the health care personnel affected by the impacts of medication errors since they are mostly in charge of administration and monitoring patient conditions following medication. According to studies done in the United States, approximately 251,000 patients die annually following medical administration errors. Medical administration errors have been known to predispose patients, family members, and clinicians to a disability, huge losses, lawsuits, and deaths. The root cause analysis offers to provide sufficient data and analysis geared towards possible solutions for the health care professionals and patients towards understanding and fighting medical administration errors hence preventing future occurrence of disability and deaths (Hydari, Telang, & Marella, 2019).

The various concern on the medical administration errors came into light during 1999 publication by the Institute of medicines report and the news coverage on individuals injured as a result of adverse drug reactions. Public awareness of medical errors has also been credited by the joint commission on accreditation of health care as a causative agent of increased costs and reduce the confidence of the public on health issues. The majority of patient injuries resulting from drug therapies form the largest percentage of the errors. The most affected people are the nurses and patients since they are in charge of drug administration and patient care (Glavin, 2010).

Root cause analysis refers to the process of identifying the causal factors that govern variations towards health performance. The variation in the medical error is likely to cause sentinel events. The root cause analysis is required to identify the cause of the medical error and develop various strategies in place to prevent future occurrences of the same.

The majority of the medical administration error is attributed to several factors and occurs in any medical facility such as the hospital, clinics, medical office, nursing home, pharmacy, patient home, and surgery centers among other places where patient health is involved. The medical errors are involved in these places and my highly be distinguishes and possible solution identified towards the problem.

The most common cause of medication administration errors results from medical personnel or equipment used inpatient treatment. A study conducted by the backer demonstrated, one of every five administered doses resulted in an error. Wrong time accounted for 43%, omission 30%, wrong dosage 17%, and others 10 % of the errors. Incidence of the medication errors varied depending on the stage of dispensing and the individual study was classified as wrong time, wrong dosage, and omission. 70% of the cases are related to prescribing errors, 10% administration errors, 10% documentation errors, 7% errors relating to dispensing of medicines, and 3% patient monitoring errors after medication administration. Learning how to identify, prevent and monitor medical administration structure is critical in changing standards of health care to reduce attributes of medical error and negligence. Through an established root-cause analysis aimed at eliminating medical administration errors, the health care system and health care provides can safeguard patient’s health and prevents lawsuits in addition to reducing the cost of medical operation.

The major cause of medical administration error often results from the failed system rather than individual compliance with multiple factors influencing the process. Of importance is communication breakdown from the medical personal and patients. The communication can be informed of verbal or written communication. Any medical procedure that is not documented is treated as not done to the patient. The medical personnel’s handwriting may be a challenge to interpretation and the use of non-standardized abbreviations can mislead the medical team leading to medical errors such as wrong dosage, wrong drug, and timing of the drug. A good communication system should identify the patient correctly, provide legibly handwrite on the prescription and dosages. The medical personnel ought to avoid the use of non-standardized abbreviations in prescriptions and the nurse to indicate when the patient received the drug, dosage and when the next dose is due to avoid errors (Abdi, et al.,2015).

Work-related factors are also attributed to medical errors such as long working hours, excessive work, or dealing with a complicated medical procedure that doesn’t match the nurse’s experience. Such conditions often resulted in fatigue and sleeplessness as registered nurses were reported to work more than 40 hours a week. The chances of making medication errors often increased following long working hours and increased three times more when the nurses worked more than 12 hours per shift. Equally working overtime increased the risk of making errors.

The skill mix often resulted in medical errors that consisted of a myriad of challenges such as understaffing of medical personnel, lack of effective equipment, inexperience, and working under unfavorable conditions. The equally poorly designed procedure often leads to medication errors. Other related issues are the patient issues such as inappropriate patient identification, lack of patient education, and failure to obtain consent towards patient treatment.

From the presented root cause of the medical error, the organization ought to have proposed the normal working hours for the patient and ensure the facility is adequately staffed with the correct medical procedure and equipment. Nursing should work for a maximum of 8hours, employees ought to be effectively trained, and correct structures established to support patient care. The environmental factors also attribute to medical errors such as poor lighting and room temperature can influence medication. Certain drugs are known to be light-sensitive hence exposure to light may reduce the desired effect causing underdosing or toxicity. The working environment equally determines the quality of care in that poor working environment contributes to medical errors (Huq, et al., 2016).

Application of evidence-based strategies to reduce medication errors

Medical administration errors can be addressed basing on the root cause of the problem. The majority of the errors were attributed to personal factors with nurses having the highest number, environmental and communication factors among others. Addressing the stated factors serves to prevent the future occurrence of medication administration errors. The use of advanced nurses’ practice has been linked to the utilization of evidence-based practice to reduce medication errors. The use of education in service is aimed at improving patient care through consistent and organized patient care.

Medication errors resulting from the prescribing can be addressed by computerized physician order entry. Other factors attributed to prescribing errors include tasks and individual factors. The use of computerized physician order entry has been largely been linked electronically to other departments such as the pharmacy thus reducing errors in medication. Implementing the use of a clinical support system to guide on the dosages, frequency, and side effects of the drugs.

Attributes aimed at minimizing medication error as a result of dispensing include the use of automated dispensers and minimizing the illegibility of the prescription. Also, use of robots for dispensing medication. Establishing a just culture in the medical field is critical to address the individual causes of medical error. This is aimed at training and establishing changes in behavior aiming at supporting and consulting individuals who are found to be engaged in medical administration error. Withdrawing incentives for the offenders and establishing them for those with good performance and equally punishing reckless behavior (Mwawule, & Bacia, 2019).

Improvement plan with evidence-based and best practice strategies

The improvement plan involves two approaches; creating awareness on medication errors, education towards addressing the challenges, and improving technology towards drug administration. Education is the basis of effective patient management and limits the incidence of medical errors when the nurses are frequently trained at work and on current emerging trends in patient management. The use of technology reduces the human challenges associated with medical errors. Technology can offer a wide variety of prescription, dispensing, and analyze of the drugs, duration of administration to prevent medical errors. the system can link different departments to reduce the challenges of prescription such as the pharmacy. The duration of the interval is dependent on the approach used to reduce medication administration errors (Wong, Levinson, & Shojania, 2012).


Medical administration errors are the leading causes of patients’ suffering, death, and huge costs in seeking medical care. Medical personnel such as nurses are highly affected based on their close relationship to patient care and management. Some of the causes of medication administration errors occur due to poor communication, poor working conditions, personal attributes, and lack of adequate knowledge. The causes of medication administration errors can highly be prevented through several evidence-based practices aimed at creating awareness and use of technology towards patient care and drug administration.


Dolansky, M. A., Druschel, K., Helba, M., & Courtney, K. (2013). Nursing student medication errors: a case study using root cause analysis. Journal of professional nursing, 29(2), 102-108.

Hydari, M. Z., Telang, R., & Marella, W. M. (2019). Saving patient Ryan—can advanced electronic medical records make patient care safer?. Management Science, 65(5), 2041-2059.

Glavin, R. J. (2010). Drug errors: consequences, mechanisms, and avoidance. British journal of anesthesia, 105(1), 76-82.

World Health Organization. (2016). Consultative meeting planning for the global patient safety challenge: medication safety, 19-20 April 2016, WHO Headquarters Geneva, Switzerland: meeting report (No. WHO/HIS/SDS/2016.20). World Health Organization.

Wong, B. M., Levinson, W., & Shojania, K. G. (2012). Quality improvement in medical education: current state and future directions. Medical education, 46(1), 107-119.

Mwawule, F. W., & Bacia, L. (2019). Assessment of medication errors at the in-patient wards of Arua Regional Referral Hospital, Arua District, Uganda (Doctoral dissertation).

Huq, M. S., Fraass, B. A., Dunscombe, P. B., Gibbons Jr, J. P., Ibbott, G. S., Mundt, A. J., … & Yorke, E. D. (2016). The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics, 43(7), 4209-4262.

Abdi, Z., Delgoshaei, B., Ravaghi, H., Abbasi, M., & Heyrani, A. (2015). The culture of patient safety in an Iranian intensive care unit. Journal of nursing management23(3), 333-345.