ROOT CAUSE ANALYSIS ACTION PLAN

Root Cause Analysis Action Plan

Purdue University-Calumet
Nursing 45200
Flo Nite

ROOT CAUSE ANALYSIS ACTION PLAN

Background
Problem Statement and Chosen Cause that will Drive Improvement
The problem chosen was an error on administration of immunizations to patients due to
not checking patients immunization records carefully prior to administration. The problem
occurred when a patient came to the clinic for a well-child examination for school. After the
patient was examined by the physician, the third dose of Gardasil was ordered for the patient.
After administration of the vaccine, the nurse went to enter the immunization into the patients
records when she noticed that the first dose of Gardasil was given October 2014, but the second
dose was administered May 2014. The nurse investigated and realized that the previous nurse
that administered the vaccination in October, was supposed to document it as the third dose, but
instead documented it as the first dose, which led to administration of the fourth dose, think that
it was the third dose.
The purpose of this action plan is to try to prevent errors in administration of
immunizations whether it is an extra dose or administering too early, which then requires
revaccination. The reason this problem was select is because majority of the immunizations
comes from Vaccines for Children Program (VFC). VFC is a federally funded program that
provides vaccines at no cost to children that might not be vaccinated because of inability to pay.
Center for Disease Control (CDC) purchase vaccines at a discounted price and distributes it to
the VFC programs. Even with a discounted price, the cost of one dose of Gardasil cost $121.03.
An extra dose of Gardasil did no harm to the patient, but a dose was wasted because it was
administered to a patient that did not need it. That dose could have been used for another patient
who needed it.

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Current Knowledge of the Problem (State and National Context)

Administration of immunizations is considered a national quality goal, because it is
categorized as Clinical Preventative Services. Evidence-based preventive services are effective
in reducing death and disability, and are cost-effective or even cost-saving. Preventative services
consist of screening tests, counseling, immunizations or medications used to prevent disease
(National Prevention Strategy, 2011). Despite the fact that clinical preventative services are
covered by Medicare, Medicaid, and many private insurances under the Affordable Care Act,
millions of children, adolescents, and adults go without these services that could protect them
from serious diseases (Clinical Preventive Services, 2015).
Using the example of the patient that received an extra dose of Gardasil, the benchmark
for vaccination of Gardasil to females and males is targeted at 80%. Looking at the Healthy
People 2020 objectives, IID 11.4 and IID 11.5 states 16.6% of females aged 13-15 and 6.9%
of males aged 13-15 received three doses of Gardasil (Immunization and Infectious Diseases
Objectives, 2015). Immunization of Gardasil is far below the target benchmark of 80%, but
currently there is no mandatory consequence if these benchmarks are not achieved.
It is noted that under-immunization is more prevalent than extra-immunization. Underimmunization is a public health problem while extra-immunization is primarily an administrative
failure (Darden, Gustafson, Nietert & Jacobson, 2011). In an effort to immunize the population,
there are cases where the population is getting extra immunized. While extra immunization does
not harm the patient, but extra-immunizations incur cost to the parent, child, provider, and payers
which is not cost efficient, when vaccines cost a lot. The cost of vaccines is listed on the CDC
website and can be found at http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-

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management/price-list/index.html. The rate for extra-immunization for U.S. children aged 19-35
months was 9.4% and children from racial/ethnic minorities were more likely to be overvaccinated. Extra-immunization causes may include lack of documentation or problems with the
communication of previous immunizations, mismanagement of a lapse in the sequence of
immunizations, or simply a misunderstanding of the routine vaccination schedule (Darden,
Gustafson, Nietert & Jacobson, 2011).
Proposed Improvement Plan and Rationale
Proposed Improvement Intervention
Well-designed order sets both electronic and paper formats have the potential to
coordinate care by communicating best practice, reducing variations and unintentional oversight
through standardized formatting and clear presentation of orders, enhanced workflow with
pertinent instructions that are easily understood. However, if standard order sets are not carefully
designed, review and maintained to reflect best practice and ensure clear communication, they
may contribute to errors (ISMPs Guidelines for Standard Order Sets, 2010). Good record
keeping, maintaining careful patient histories and adherence to recommended schedules can
decrease the chances that patients receive extra doses of vaccines (Providers Role: Importance
of Vaccine Administration and Vaccine Storage & Handling, 2014). The Joint Commissions
National Patient Safety Goal #13 requires accredited facilities to encourage the patients active
involvement in their own care as a safety strategy, this can be done, by writing down the names
of vaccines the patient needs beforehand or giving vaccine information statements (VIS) before
each vaccination is given (Preventing vaccine administration errors, 2015).

ROOT CAUSE ANALYSIS ACTION PLAN

From the root cause analysis, one cause listed was that the nurse did not check the
patients records before administering the vaccination. The first intervention would be for the
nurse to check the patients immunization records prior to giving any immunization. This
intervention is a weak action, because it requires the nurse to double check the orders. The
second intervention would be after checking the immunization records carefully, the nurse will
write down what immunizations the patient is missing and the dosage prior to seeing the orders
from the physician. So if there is any discrepancy, communication should happen between the
nurse and physician prior to any immunization given. This intervention is an intermediate action
since it requires enhanced documentation, meaning writing down the type of vaccine that will be
given and the dosage before administering, and communication happens between the physician
and nurse if there is a discrepancy. By implementing the first and second intervention, this
becomes a strong action, because the process is standardized, by having the nurse check the
records and comparing it to what the physician orders. Before these interventions, the only
barrier to prevent error is the physician looking at the records and placing orders. Now you have
the nurse and the physician both looking at the records to see if there is any error. The third
intervention would be to include the patient and their family involvement in their care as a safety
strategy. This intervention is an intermediate action, because the family is considered a checklist,
if they remember what immunization they had previously received or if they presented their
immunizations records during every visit, so that documentation can be made if they received
other immunizations from other clinics.
Proposed Implementation Plan
Implementation of the interventions would involve the physician, nurse, and the patient
and their family. For the first intervention of checking records prior to administration, there

ROOT CAUSE ANALYSIS ACTION PLAN

would be an implementation that the nurse needs to check all immunization records prior to any
immunization administered. Meaning that the nurse should have already checked the patients
records and know what immunizations the patient will be receiving during that visit prior to the
physician ordering them. The second intervention would require that the nurse writes down what
immunizations and the dosage that the patient will need before the physician orders them. If
there is a discrepancy after viewing what the physician has ordered, then the nurse needs to
communicate with the physician and question the order. The nurse should not rely solely on the
orders of the physician, since the physician can make mistakes too. The main focus of
questioning discrepancies is solely for providing best practice for the patient and not by ranking
between a nurse and a physician. The third intervention is to include involvement of the patient
and family in their own care. Giving VIS to the patient will let them know what immunizations
they are receiving. Encouraging them to bring their immunizations records will reminded them
of what immunizations they have already received. If a patient is receiving series immunizations,
a reminder sheet of listing the name of the vaccine, what dosage in the series, and the date that it
is due will help the patient know what vaccinations they still need. Implementation of the
improvements would be based on each individual clinic. The reason for this is, because each
clinic is different and their process of receiving orders and documentation is different in every
clinic.
Proposed Measures to Evaluate Effectiveness
The target of this action plan is to prevent extra immunizations for patients. Measurement
of effectiveness would be checked once a week for a three month period, where a report would
be pulled from the EMR system for that entire week of all the patients between the ages of two
months to eighteen years old that came for a physical examination. From that report,

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immunization records would be checked to see if patients are up-to-date on all immunizations
required during that age, and to see if errors were entered into the records. Each immunization
given is recorded into the patients record, by documenting, the name of the vaccine, who
administered it, the route of administration, location of the injection, name of manufacturer,
expiration date, and the VIS date. If errors are found, approach the person that administered the
vaccine and give them a reminder to document carefully. If errors are found, corrections can be
made to the EMR system prior to the patients next visit, so errors of extra immunizations would
not occur. The data outcome would be shared between the physician and nurses.

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References
Centers for Disease Control and Prevention (CDC) (2014, May 19). Providers Role: Importance
of Vaccine Administration and Vaccine Storage & Handling. Retrieved from
http://www.cdc.gov/vaccines/recs/vac-admin/providers-role-vacc-admin-storage.htm
Centers for Disease Control and Prevention (CDC) (2015, July 1). Vaccines for Children
program (VFC) CDC Vaccine price list. Retrieved from
http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/pricelist/index.html
Darden, P.M., Gustafson, K.K., Nietert, P.J., & Jacobson, R. M. (2011). Extra-Immunization as a
Clinical Indicator for Fragmentation of Care. Public Health Reports, 126 (Suppl 2): 4859.
Healthy People 2020 (July 2015). Clinical Preventive Services. Retrieved from
http://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/ClinicalPreventive-Services
Healthy People 2020 (July 2015). Immunization and Infectious Diseases Objectives. Retrieved
from http://www.healthypeople.gov/2020/topics-objectives/topic/immunization-andinfectious-diseases/objectives
Institute for Safe Medication Practices (2010). ISMPs Guidelines for Standard Order Sets.
Retrieved from http://www.ismp.org/Tools/guidelines/StandardOrderSets.pdf

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Institute for Safe Medication Practices (2015, January 1). Preventing vaccine Administration
errors. Retrieved from http://www.pharmacist.com/preventing-vaccine-administrationerrors
National Prevention Council (June 2011). National Prevention Strategy Americas plan for
better health and wellness. Retrieved from
http://www.surgeongeneral.gov/priorities/prevention/strategy/report.pdf