NURS4020 Root-Cause Analysis and Safety Improvement Plan Essay

NURS4020 Root-Cause Analysis and Safety Improvement Plan Essay

Root-Cause Analysis and Safety Improvement Plan

In everyday practice, nurses and other health care providers are advised to apply strategies that keep care quality and patient safety at optimal levels. They need to collaborate, use appropriate technologies, and avoid practices that risk patient safety. Despite the commitment to achieving the set goals, issues that pose a significant risk to patient safety still occur. The impacts vary depending on the type of the issue and the people affected. Addressing such issues requires a comprehensive analysis of the contributing factors through root-cause analysis. Such analysis is the foundation of solution generation to improve safety and prevent a recurrence. The purpose of this paper is to provide a root-cause analysis of a patient safety issue and a safety improvement plan.


Analysis of the Root-Cause

Patient safety problems differ in causes, magnitude, and required interventions. Some issues affect a specific practice area, while others are system-wide. In any case, the exact cause should be known to establish practical solutions. In health practice, root-cause analysis is a practical approach for discovering the root causes of problems. It recommends looking beyond the superficial cause of an issue to go deeper into processes and systems failures and their connection to the issue (Kwok et al., 2020). The approach is based on the tenet that there is more to patient safety issues besides the surface view.

The patient safety issue guiding this root-cause analysis and safety improvement plan occurred in a neonatal centre’s intensive care unit (ICU). It involved a premature baby whose glucose levels had declined and required elevation. In such instances, a heparin infusion is highly recommended to inhibit insulin binding and stimulation (Wang et al., 2019). In response, the dispensing nurse administered the medication as appropriate. After six hours, it was discovered that there was no change in the glucose levels as expected. The neonatologist further requested an analysis of the Total Parenteral Nutrition (TPN) infusion. It emerged that the infusion contained insulin instead of heparin. The baby died after two days.

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To guide decision making, it is crucial to examine the environmental, practice-based, communication errors and other factors that contributed to the problem. Firstly, ICUs are high-risk areas since nurses must act quickly to save a patient’s health. They also deal with sensitive patient health concerns that need accuracy besides promptness. Despite the need for such responses, the pressure to act quickly increases the chances of human error (Rodziewicz et al., 2021). Unless collaboration is high and dispensing nurses follow all the necessary protocols, issues with far-reaching effects on patients are inevitable.

Besides operating in a high-risk environment, the dispensing nurse also failed to follow the proper protocols for medication administration. According to Salman et al. (2020), heparin and insulin are available in premixed, prefilled syringes ready for use. Besides, their containers and tops are usually similar. As a result, medication confirmation before administration is essential. However, the dispensing nurse took the infusion readily available and administered it, assuming that it was heparin. Failing to confirm drugs before administration increases the chances of committing serious errors.

Other factors exacerbated the problem in conjunction. For instance, the dispensing nurse was new in the facility and handled the case alone when the issue occurred. In such a case, the nurse is supposed to work under an experienced colleague conversant with medication locations and administration protocols in the facility. The new nurse is also supposed to communicate with other nurses to ensure medication reconciliation and other processes occur as expected. Above all, it was realized that insulin and heparin were stored closely. Close storage of drugs similar in many characteristics increases the chances of confusion and errors.

Generally, many factors inhibited proper medication administration. It is right to deduce that it was a case of negligence and not being unable to do what is right. A patient’s death is among the adverse events that health care providers must avoid by all means. Tariq et al. (2018) found that patient safety problems consume massive resources to manage and erode patients’ trust in care providers. A death also affects families and care providers emotionally and mentally. Health care providers can doubt their ability or get traumatized by an event leading to secondary victim syndrome (Ozeke et al., 2019). Due to the far-reaching consequences of such issues, evidence-based and best practice strategies should be applied.

Application of Evidence-Based Strategies

The patient safety issue represents medication dispensing error. According to Tariq et al. (2018), approximately 7,000 to 9,000 people die in the United States die yearly due to medication errors, and the total cost of care for patients with medication-associated errors exceeds $40 billion annually. As illustrated in the issue analysis, system issues, protocol and procedure hitches, and communication challenges triggered the adverse event. In this case, the medication dispensing error is a multifaceted problem requiring multifaceted interventions.

Regarding protocols and procedures, medication errors are high in settings where health care providers fail to work collaboratively. In this case, health care providers need to work collaboratively and guide each other where necessary. It is also crucial to adopt the appropriate technologies in health care delivery. ICUs are critical areas and do not give any chance of committing errors. All procedures should be accurate. Technologies that facilitate patient identification, drug location, and drug confirmation should always be used. The efficacy of technology is high since it is above 95% in ensuring that the right patient consumes the right drug (Campmans et al., 2018). Correct location and confirmation should be standard practice. This important step was not followed.

Besides technologies, the importance of teamwork cannot be underestimated when handling patient safety issues. The problem could have been prevented if the new nurse had worked alongside others to address the critical issue. The chances of committing a medication error are high when working in a new setting, regardless of a nurse’s experience. Other nurses could have assisted the new nurse with drug location, identification, and confirmation. The baby could also have been monitored closely and the progress noted to facilitate early intervention.

Safety Improvement Plan with Evidence-Based and Best-Practice Strategies

Proposing intervention strategies or solving an issue when it emerges does not address it comprehensively. It is crucial to have a safety improvement plan with actions, new processes, policies, policies, and goals. A timeline for guiding the implementation plan should be explicit. To a significant extent, the patient safety issue could have been avoided if the medication had been confirmed before dispensing. As a result, the neonatal center should adopt barcode scanning technology to facilitate this process. Mulac et al. (2021) found barcode scanning effective in preventing medication errors by ensuring adherence to the five rights of medication administration. It should also be mandatory for nurses to confirm and reconfirm all medications before administration.

Besides barcode scanning, teamwork should be mandatory in critical health care units. Regardless of the time and patients being handled, nurses should work in teams. Achieving this goal will require the nurse leader to design new duty rosters with nurses grouped in numbers that vary depending on the expected patient acuity and flow. Teamwork improves communication and interprofessional collaboration, as nurses consult each other on critical issues (Tariq et al., 2018). It is also crucial to ensure that all drugs are stored in electronic cabinets, labeled correctly, and drugs that can be confused easily to be kept away from each other. Salman et al. (2020) recommended the storage of insulin and heparin away from each other since the probability of confusion is high. The same should be embraced in the neonatal center. To ensure adherence to the proposed work routines, nurses should also be trained to accustom them to technology use, new workplace protocols, and drug storage procedures.

A safety improvement plan is designed with some desired outcomes in mind. The first outcome expected from this plan is high accuracy during medication administration. The second outcome is promoting teamwork in practice. Thirdly, the plan intends to promote evidence-based practice by incorporating technology in health care delivery. The other objective is eliminating professional, ethical and legal issues associated with medication errors’ problems. The patient-provider relationship should not be adversely affected, and the neonatal center should be free from legal and ethical accusations.

A timeline is also essential for a safety improvement plan. The entire plan is expected to be fully implemented within six months. The management and the information technology (IT) department should identify and adopt appropriate technologies within two months. Nurse leaders should design new work schedules within a month. The change in storage protocols, including labeling, should take a month. Training on the changes, evaluation, and designing mechanisms to sustain the changes should take two months.

Organizational Resources for Safe Medication Administration

Organizational changes cannot succeed if an organization is not adequately capacitated to support the change. The existing resources can be leveraged to achieve the desired results or rely on new resources. Human resources, facilities, and knowledge are existing organizational resources that can be leveraged to implement the plan successfully. Human resources include the management, nurse leaders, and the IT department. Facilities include a training venue since the training will be conducted internally. Knowledge includes information technology skills, which will be pivotal in adopting barcode scanning and electronic storage cabinets. However, internal resources will not be enough to support the desired change. The facility will be required to purchase barcode scanners and new computers through the management and IT department’s guidance and support. External trainers would also be required to ensure that nurses are conversant with their actions’ legal and ethical implications when using health care technologies.


Patient safety issues have far-reaching consequences on the patient’s health, patient-provider relationship, and an organization’s reputation. Accordingly, they should be prevented by all means. The case study of a premature baby dying due to insulin-heparin confusion exemplifies the severity of medication administration errors in health care settings. Avoiding such errors requires health care facilities to adopt evidence-based and best practice strategies. As discussed in this paper, such strategies include using appropriate technologies for medication confirmation, working in teams, and proper drug storage. A safety improvement plan is also vital to adopt and sustain best practices as situations necessitate.


Campmans, Z., Van Rhijn, A., Dull, R. M., Santen-Reestman, J., Taxis, K., & Borgsteede, S. D. (2018). Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—A survey of users. PLoS One13(5), e0197469.

Kwok, Y. T. A., Mah, A. P., & Pang, K. M. (2020). Our first review: An evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals. BMC Health Services Research20(1), 1-9.

Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. G. (2021). Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Quality & Safety30(12), 1021-1030.

Ozeke, O., Ozeke, V., Coskun, O., & Budakoglu, I. I. (2019). Second victims in health care: Current perspectives. Advances in Medical Education and Practice10, 593–603.

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls [Internet].

Salman, M., Mustafa, Z. U., Rao, A. Z., Khan, Q. U., Asif, N., Hussain, K., Shehzadi, N., Khan, M., & Rashid, A. (2020). Serious inadequacies in high alert medication-related knowledge among Pakistani nurses: Findings of a large, multicenter, cross-sectional survey. Frontiers in Pharmacology11, 1026.

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention. StatPearls [Internet].

Wang, A. J., Ren, J., Abbadi, A., Wang, A., & Hascall, V. C. (2019). Heparin affects cytosolic glucose responses of hyperglycemic dividing mesangial cells. The Journal of Biological Chemistry294(16), 6591–6597.


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.
Use the scoring guide to understand how your assessment will be evaluated.

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