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Assessment 2: Root Cause Analysis and Safety Improvement Plan

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Student Name

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Capella University

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Course Name
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Nov 6, 2023
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Root Cause Analysis and Safety Improvement Plan
Root Cause Analysis (RCA) serves as an effective methodology for identifying factors
contributing to patient safety risks. The healthcare organization under consideration has
witnessed a notable prevalence of medication administration issues and adverse events,
highlighting the critical importance of patient safety. RCA plays a pivotal role in mitigating

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preventable adverse events, enhancing patient safety measures, and fostering learning and
quality improvements within healthcare settings. Notably, medication errors, particularly in
administration, rank as the eighth leading cause of death in the USA. Numerous studies

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underscore medication administration errors (MAEs) as prominent contributors to patient safety
risks in acute care settings, leading to prolonged hospital stays (Samsiah et al., 2020). This
review specifically delves into the root causes of drug administration errors in the diabetic ward,

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focusing on evidence-based safety improvement strategies and organizational interventions to
bolster patient safety.

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Analysis of the Root Cause
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Mr. Wallace's experience in the diabetes ward reflects various root causes of medication
administration errors. Factors discussed in Assessment 1 include inadequate training, deviation
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from medication administration guidelines, insufficient work experience, interruptions during
administration, communication inefficiencies, lack of knowledge, and human factors contributing
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to errors impacting patient safety (Ulrich et al., 2022; Schroers et al., 2020; Wondmieneh et al.,
2020). Studies reveal a positive correlation between nursing staff experience and the quality of
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patient care, emphasizing the significance of ongoing training (Ulrich et al., 2022).
Communication gaps among healthcare professionals, including nurses, clinicians, and
colleagues, often result in medication administration errors (Samsiah et al., 2020).
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Qualitative assessments highlight a prevalent lack of medication knowledge among nurses,

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emphasizing the need for targeted interventions (Schroers et al., 2020). Deviation from
guidelines and the absence of appropriate protocols significantly elevate the risk of medication
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errors (Wondmieneh et al., 2020). Minimizing interruptions during administration processes is

crucial, and human factors such as work stress, prescription errors, and lack of experience
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contribute substantially to MAEs (Brigitta & Dhamanti, 2020).

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Application of Evidence-Based Strategies

To address obstacles contributing to safety issues associated with medication administration
errors, evidence-based strategies are imperative. Nurse training and education play a pivotal
role in reducing errors, with a focus on the "five rights" of pharmaceutical administration (Yoon &
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Sohng, 2021). Implementing Barcode Medicine Administration (BCMA) systems significantly
reduces the likelihood of administrative mistakes (Fitzhenry et al., 2020). Smart infusion pumps
with Dose Error Reduction Systems (DERS) and Clinical Decision Support (CDS) Systems
contribute to error reduction during drug administration (Melton et al., 2019). Cultivating a safety
culture, open communication, and non-punitive reporting procedures are essential for
addressing errors and enhancing patient safety.

Evidence-Based Safety Improvement Plans

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Safety improvement plans aim to reduce errors leading to adverse events through the
systematic integration of root cause analysis and multiple-solution strategies. Establishing a
blame-free culture emphasizes addressing the causes of errors rather than attributing blame,

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facilitating timely interventions, and preventing morbidities (Carver & Hipskind, 2019). Effective
communication and collaboration between healthcare professionals positively impact the quality

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of patient care (Visvalingam et al., 2023).

Root-Cause Analysis and Safety Improvement Plan

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Implementing technological tools such as BCMA and CDSS streamlines medication
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administration, ensuring accurate records. The Lean Six Sigma Plus methodology, focusing on
process standardization and waste reduction, proves valuable in hospitals for minimizing errors
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(McDermott et al., 2022).
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Organizational Resources
Optimal utilization of existing and potential organizational resources is essential for maximum
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impact. Hospitals should invest in staff training, technologically advanced tools, and strategies
for patient care. Financial resources can support staff training and the incorporation of
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technological tools. Involving multidisciplinary teams and professional organizations enhances

standardization and best practices, ultimately reducing adverse events.
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Conclusion
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Medication errors in acute care settings necessitate systematic root cause analysis to prevent
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future occurrences. Evidence-based approaches, such as the LSS method, provide

comprehensive solutions. Leveraging organizations like Nursing Associations and MSOS
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maximizes the impact of safety improvement plans.

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References
Carver, N., & Hipskind, J. E. (2019). Medical Error. StatPearls Publishing.

FitzHenry, F., et al. (2020). Prevalence and risk factors for opioid-induced constipation in an
older national Veteran cohort. Pain Research and Management, 2020.

McDermott, O., et al. (2022). Lean Six Sigma in healthcare: A systematic literature review on
motivations and benefits. Processes, 10(10).

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Melton, K. R., et al. (2019). Smart pumps improve medication safety but increase alert burden in
neonatal care. BMC Medical Informatics and Decision Making, 19(1).

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Samsiah, A., et al. (2020). Knowledge, perceived barriers and facilitators of medication error
reporting: a quantitative survey in Malaysian primary care clinics. International Journal of Clinical

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Pharmacy, 42(4).

Schroers, G., et al. (2020). Nurses’ perceived causes of medication administration errors: A

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qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety,
47(1). gn
Ulrich, B., et al. (2022). National Nurse Work Environments – October 2021: A Status Report.
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Critical Care Nurse, 42(5).
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Visvalingam, P. A. A., et al. (2023). A systematic review of knowledge, attitude, practice and the
associated factors of medication error among registered nurses. IJFMR – International Journal
for Multidisciplinary Research, 5(4).
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Wondmieneh, A., et al. (2020). Medication administration errors and contributing factors among
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nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(4).
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Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting
system. Nursing Open.
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