NURS-FPX4020: Root-Cause Analysis and Safety Improvement Plan Project

This assignment presents a root-cause analysis of a patient safety issue at Clarion Court Skilled Nursing Facility in Shakopee, MN, where medication errors increased over six months, culminating in a near overdose. The analysis identifies negligence by nursing staff and supervisors in detecting and addressing the problem as the root cause. The improvement plan proposes educating nurses on the 'five rights' of medication administration within two months and establishing a monitoring team within one week to detect and prevent future errors. The plan emphasizes evidence-based practices and best practices to enhance patient safety and prevent the recurrence of adverse events. The document provides a detailed analysis of the root causes and proposes actionable strategies for improvement, including implementation timelines and resource allocation.

Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
Root-Cause Analysis and Safety Improvement Plan
YOUR NAME
NURS-FPX4020
Capella University
Month, Year
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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
Root-Cause Analysis
In a health care facility, named Clarion Court Skilled Nursing Facility in Shakopee, MN,
there was an observation of continuous rise in the medication errors all through the last six
months. The problem only came into focus one week prior after a serious error in administering
the medication led to almost overdose. As a charge nurse the problem should be addressed with
utmost priority since for a nursing facility and a nursing staff the patient safety is one of the
priorities. The paper is going to make an analysis of the root cause along with an improvement
plan, which will include the evidence based and best practice strategies.
Analysis of the Root Cause
Prescribing wrong medication or a wrong dose of medication, administration of a medication by
wrong route can be considered as medication errors (World Health Organization, 2016). The
Clarion Court Skilled Nursing Facility experienced medication errors, which kept increasing in
rate with time for six months before the problem could come into focus of the administration
department of the nursing facility. An event of nearly overdosing of a patient was the point when
the matter came into the focus of the administration facility. The problem presented the high risk
in regards to the patient safety. The main problem in regards to this issue was not the error events
but how the repetitions went un-noticed for six months and it nearly resulted in the death of a
patient, which was a serious issue regarding the maintenance of the patient safety. The problem
is not only was a risk for the patients’ health of that nursing facility but also a risk to the
reputation of the facility.
The nursing facility should have kept a continuous watch on the events that can effect negatively
on the quality of patient care along with the patient safety. If the proper measures were taken to
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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
detect the error in the practices that present the risk of safety to the patients, the first error would
have been identified before the rate could increase and the continuation of the mistake could last
all though the six months. After the detection of the error the proper action should have been
taken in order to prevent the repetitions of the same mistake.
The supervisors of that nursing facility were ignorant along with the nursing staffs themselves to
the arising problem of medication error. It can be predicted from the event that the nurses did not
have proper knowledge on the right medication, right dose and the right administration procedure
for the medication. Thus when the problem arose the nurses were unable to find the solution to
the problem. This factor was controllable and could be avoided if the nurses were educated
properly and warned about the scenario. There is no factors related to the equipments or
resources that can be identified to have any contribution in this matter due to shortage of the
information provided in the case study. The actions of the nursing staffs while making the
mistake of the error practice can be considered as the main human error. The second human error
was the inability to detect the mistake even after possible show of adverse effects in the patients.
Ineffective communication with the patient was one of the possible reasons for which the effects
of those medication errors might have gone unnoticed this long. The root cause of this problem
was the negligence of the nursing staffs and their supervisors in detecting the problem of
medication error for six months.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The first strategy to prevent the medication error can be providing the nurses proper
education on the five rights of administering medications, which involve the correct patient,
correct medication, correct dose and correct route of administration along with the correct
administration time (Blignaut, Coetzee, Klopper & Ellis, 2017). A proper knowledge on those
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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
factors will help the nursing staffs from making the mistakes, which can result in the medication
error. The next action plan can be the development of proper monitoring team that will monitor
the rate of error occurring in the nursing facility along with identifying the reasons behind those
errors (Schnock et al., 2017). The implementation of this plan will be able to detect the problem
in time, which will result in taking the proper and timely actions in order to prevent the adverse
effects on the patients that is likely to result from the medication error.
Thus the nursing goals for lowering the instances of medication error is educating the
nursing staffs about the possible error practices along with the possible adverse effects on the
patients and developing a proper monitoring team for the timely detection of the error events in
order to take timely actions against them.
The rough timeline of two months can be set for implementing the first action plan, since
educating all the nurses is most likely to be time consuming matter. The next action plan of
developing a monitoring team should be done with one week of time.
Existing Organizational Resources:
In order to educate the nurses the organization should appoint some proper nursing
professionals to provide the proper education. Along with that the senior nursing staffs including
the nurse leaders of the nursing facility should involve in teaching the junior staffs.
The monitoring team should include properly experienced staff including the chief nurse,
who will be able to detect the problems easily and will be able to make timely decisions in case
of the error events.
Conclusion
Hence it can be concluded from the above study that the root cause of the problem of increasing
rate of medication error was the negligence of the nursing staffs and the authorities of the nursing
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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
facility in detecting the problem and taking proper measures against the problem. The action
plans as part of the improvement plan are educating the nursing staffs on the five rights of proper
administration of medication within two months and the development of the proper monitoring
team within one week.
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ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN
References
Blignaut, A. J., Coetzee, S. K., Klopper, H. C., & Ellis, S. M. (2017). Medication administration
errors and related deviations from safe practice: an observational study. Journal of
clinical nursing, 26(21-22), 3610-3623.
Schnock, K. O., Dykes, P. C., Albert, J., Ariosto, D., Call, R., Cameron, C., ... & Husch, M. M.
(2017). The frequency of intravenous medication administration errors related to smart
infusion pumps: a multihospital observational study. BMJ Qual Saf, 26(2), 131-140.
World Health Organization. (2016). Medication errors.
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