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

May 15, 2023 | Nursing | Capella FlexPath | FPX4020 | 52

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.

Apply evidence-based and best-practice strategies to address a safety issue or sentinel event

pertaining to medication administration. ;

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

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

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.

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.

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


4/22/2021 Assessment 2 Instructions: Root-Cause Analysis and Safety ...


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 Template [DOCX] 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


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


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.

Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you


Root-Cause Analysis

Medication error occurs when a nurse gives the patient the wrong drug, wrong dose, using the wrong route of administration, or at the wrong time. It could also occur when the patient gets adverse effects that were not expected or treated right. It could occur in a case where the drug is administered for the wrong reason. In our case, the medication error occurred when the drug interaction with the patient could have been avoided. The patient received penicillin medication and the nurse did not know that the patient was allergic to penicillin. The case scenario is extensively discussed in this paper.

Analysis of the Root Cause

After a shift change in the hospital, patient X was in the waiting room awaiting medication. The nurse who was on duty explained to him that she was in a hurry to get her child from school but the next nurse would be there in no time to attend to him. When the next nurse came in, he administered penicillin to the patient.

The patient was the first to recognize the problem. He started developing hives, rashes, swollen lips, and face. By the time the nurse on duty was alerted, he was able to prevent the anaphylactic shock stage. He administered antihistamines to reduce the inflammatory symptoms. This event created attention for the nurse with the administration. This led to disciplinary actions according to the hospital guidelines.

After looking into the case, I discovered that the nurse who administered the drugs to the patient did not know of the patient's allergy. After talking to him, he told me that the allergy had not been recorded in the patient's file report. I also talked to the nurse who was in the shift before him and she was positive she recorded the allergic condition on the patient's file. When I looked in the file, I discovered that the allergy had been recorded on a small sticky note at the back of the file. It was therefore easy to miss that information.

 My conclusion was, the two main root causes of this medical error were miscommunication and documentation. The other cause could be human error, not cross-checking medical procedures, and failing to follow the proper medication reconciliation procedures. Miscommunication was the major cause of this event. Communication could be by word of mouth or in written form. In our case failing to write about the patient’s allergy in a conspicuous place in the file led to these events.


Communication could be verbal or written. It can either be between nurses, a nurse, and a physician or a nurse and a patient. In our case, communication failed in two levels. Between the nurses and between the nurse and the patient. The second nurse should have taken the time to communicate with the patient and understand his condition. In their conversation, the patient could have probably talked about their allergy. However, this communication is not very reliable. The nurses on the other hand were obligated to properly communicate when changing shifts. Seeing the first nurse was in a hurry, there was no time for verbal communication. They would have however properly communicated via the written method. The nurse did not properly document the allergic condition of the patient. The first mistake was using a sticker note and the second mistake was not making the information conspicuous. She did not properly fill the information in the category of allergies making it hard for the nurse on duty to recognize the allergy. The nurse on duty was also at fault because he did not take his time to read through the file, otherwise, he would have noticed the sticky note.

Proper Documentation

Inadequate documentation contributes to miscommunication which eventually causes medical errors. The medical errors could cause health complications or even death (Ioannidis & Lau, 2019). Failure to document the required medication can result in the administration of the wrong dosage by another nurse. In our case failure to document the medication and to indicate the allergy was the main cause of this occurrence. The best strategy to prevent such a medical error should be proper documentation of the prescription drugs and the important details about medication, for instance, an allergy.

In our case, proper documentation and communication would prevent the occurrence of the medical error. These two factors keep the people involved in the treatment on the know. Therefore, mistakes such as knowledge-based medical errors are reduced. If the nurse documented the allergy properly, the nurse on duty could have to know the right medicine to administer.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Using Electronic Medical Record Systems

Using electronic documentation ensures the providence of accurate and up-to-date information about the patients. It also allows quick access to patient records when a nurse tries to access information. It is also advantageous because it allows sharing of a patient's information between the health workers. This system would have helped avoid a case like the administration of penicillin drugs to an allergic patient. This is because the nurse on duty could have easily accessed the information (Synappse Health, 2021). The previous nurse could have also properly documented the allergic condition and the appropriate medical prescription.

Having all hands-on deck, this system could be established in less than a month. However, taking in all the patient's records could take some time. especially in a big hospital that has many clients. The first step is building an implementation team. The next, major step is preparing the software, determining the required needs, and the patient's treatment room layout (Synappse Health, 2021). The other step that may take the longest time is data transfer, this is a continuous process because as new patients come in new records are taken. It is also important to have a troubleshooting team that also reconciles the system when it is down.

Existing Organizational Resources

Establishing an Electrical health record (EHR) system requires a team of an implementation manager. Nurse lead a team lead, and information on technology expert and a registration staff lead (Synappse Health, 2021). These staff members are responsible for establishing an electrical health record system. They should also participate in the implementation and learn how to operate the system for efficiency.


They contribute by deciding on starting and furthering the project or preventing its implementation. They also responsible for contributing to the finances and management. Their input is therefore highly valued.


The physicians, nurses, and health staff are responsible for providing input for the system. They also give live support and the workflow sign-off process. Before the purchase of the system, the clinicians test the system to ensure it meets their healthcare needs.

Office manager

They are responsible for providing input information on the demographic, billing, and the patient’s contact information. They also give information regarding the system. That is, the challenges and opportunities of the system.



In conclusion, health care providers are required to provide safe patient care. They are the primary stakeholders of care coordination and delivering safe health care practices. They are thus required to be very careful when providing treatment. This is because they are reliable to errors and especially medical errors. In our case, communication is key in preventing medical errors. Finding better communication ways to make it efficient is the best strategy in preventing such errors. Using an electrical health records system is one way to improve written communication between health care workers.



Ioannidis, & Lau. (2019). Evidence on interventions to reduce medical errors: An overview and recommendations for future research. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495210/

Melnyk. (2016, June 11). Commentary: Evidence-based care best hope to eliminate medical errors. Modern Healthcare. https://www.modernhealthcare.com/article/20160611/MAGAZINE/306119978/commentary-evidence-based-care-best-hope-to-eliminate-medical-errors

Synappse Health. (2021, April 25). Electronic medical documentation - EMR and EHR systems. SynappseHealth. https://synappsehealth.com/en/articles/i/electronic-medical-documentation-emr-and-ehr-systems/

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