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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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FEB 23, 2024

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Root Cause Analysis and Safety Improvement Plan
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Root Cause Analysis (RCA) serves as an effective methodology for identifying factors
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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
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mitigating preventable adverse events, enhancing patient safety measures, and

fostering learning and quality improvements within healthcare settings. Notably,
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medication errors, particularly in administration, rank as the eighth leading cause of

death in the USA. Numerous studies underscore medication administration errors
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(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
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the root causes of drug administration errors in the diabetic ward, focusing on
evidence-based safety improvement strategies and organizational interventions to
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bolster patient safety.

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Analysis of the Root Cause

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 from medication administration guidelines, insufficient work experience,
interruptions during administration, communication inefficiencies, lack of knowledge,
and human factors contributing to errors impacting patient safety (Ulrich et al., 2022;
Schroers et al., 2020; Wondmieneh et al., 2020). Studies reveal a positive correlation

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between nursing staff experience and the quality of 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

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medication administration errors (Samsiah et al., 2020).

Qualitative assessments highlight a prevalent lack of medication knowledge among

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nurses, emphasizing the need for targeted interventions (Schroers et al., 2020).
Deviation from guidelines and the absence of appropriate protocols significantly elevate

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the risk of medication errors (Wondmieneh et al., 2020). Minimizing interruptions during
administration processes is crucial, and human factors such as work stress, prescription
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errors, and lack of experience contribute substantially to MAEs (Brigitta & Dhamanti,
2020).
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Application of Evidence-Based Strategies
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To address obstacles contributing to safety issues associated with medication

administration errors, evidence-based strategies are imperative. Nurse training and
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education play a pivotal role in reducing errors, with a focus on the "five rights" of
pharmaceutical administration (Yoon & Sohng, 2021). Implementing Barcode Medicine
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Administration (BCMA) systems significantly reduces the likelihood of administrative

mistakes (Fitzhenry et al., 2020). Smart infusion pumps with Dose Error Reduction
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Systems (DERS) and Clinical Decision Support (CDS) Systems contribute to error
reduction during drug administration (Melton et al., 2019). Cultivating a safety culture,
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open communication, and non-punitive reporting procedures are essential for

addressing errors and enhancing patient safety.
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Evidence-Based Safety Improvement Plans

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

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2023).

Root-Cause Analysis and Safety Improvement Plan

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Implementing technological tools such as BCMA and CDSS streamlines medication
administration, ensuring accurate records. The Lean Six Sigma Plus methodology,

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focusing on process standardization and waste reduction, proves valuable in hospitals
for minimizing errors (McDermott et al., 2022).

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Organizational Resources
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Optimal utilization of existing and potential organizational resources is essential for
maximum impact. Hospitals should invest in staff training, technologically advanced
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tools, and strategies for patient care. Financial resources can support staff training and
the incorporation of technological tools. Involving multidisciplinary teams and
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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
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prevent future occurrences. Evidence-based approaches, such as the LSS method,

provide comprehensive solutions. Leveraging organizations like Nursing Associations
and MSOS 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

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Journal of Clinical Pharmacy, 42(4).

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Schroers, G., et al. (2020). Nurses’ perceived causes of medication administration
errors: A qualitative systematic review. The Joint Commission Journal on Quality and
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Patient Safety, 47(1).
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Ulrich, B., et al. (2022). National Nurse Work Environments – October 2021: A Status
Report. 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 –
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International Journal for Multidisciplinary Research, 5(4).

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Wondmieneh, A., et al. (2020). Medication administration errors and contributing factors
among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC
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Nursing, 19(4).

Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic
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reporting system. Nursing Open.

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