NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

Medication Errors Root Cause Analysis and Safety Improvement Plan Example Approach

Root cause analysis (RCA) is a tool used to investigate and understand the underlying causes of patient safety incidents, such as medication errors (Ahmed et al., 2019). It helps in problem identification so that health practitioners can introduce changes that improve care quality and patient experience. Medication errors are a typical incident that requires an RCA that will ultimately produce various recommendations to reduce medication errors and improve patient safety. The application of RCA to medication errors within a clinical care setting is critical considering the alarming numbers of increased length of stay, hospital injuries and death that adverse events have caused in American hospitals (Gates et al., 2019). For instance, according to Mazer and Nabhan (2019), at least 200,000 deaths are attributable to medication errors yearly, indicating that various root cause factors play a role in those events and are worth exploring. This report covers an RCA of ten hospitals in the US, analyzing and describing the fundamental causes and major contributors to medication errors, as well as an evidence-based plan and resources for improving patient safety.  

Root Causes Of Medication Errors And Evidence-Based Solutions

When nurses, pharmacists, or physicians offer any type of healthcare service to patients, they can unknowingly inflict injury on the patient or cause adverse events such as medication errors or misdiagnosis. As per Gates et al. (2019), 10-20% of medication orders contain medication errors depending on the adverse event, for instance, delayed medicine administration. However, Gates et al. (2019) also found out that serious medication errors make up 5% of medication administrations in the US.  In the case of Delaware Community Clinic, the management reports collected over the past 30 days indicated that for every 100 medication administration cases, seven errors are experienced. This number is above the acceptable rate of medication errors.

The data was collected through direct and non-participant medication preparation and delivery observations. The non-participatory observation of medication errors yielded important information about medication errors. For example, it was observed that distractions and secondary events were among the direct causes of medication errors in the Delaware Community Clinic. While most medication errors are preventable, they cause an array of adverse events, such as triggering new health conditions, patient injury, or, in the worst cases, death (Ibrahim et al., 2020). Medication errors also lengthen hospital stay, increases the cost of healthcare, and inflicts psychological or physical pain on the patient and their families. Medication errors in healthcare organizations reduce patient satisfaction and ultimately contribute to trust issues among nurses, physicians, and entire health organizations.

The RCA was conducted by a team of six practitioners, including a clinician, a supervisor, two quality improvement personnel and two nurses. The medication errors were recorded through nurse observations, emphasizing medication ordering and administration services. The error cases were categorized under prescription omission, wrong timing, improper usage, dose preparation and dosage, medication administration errors including extra dosage, and giving the wrong patient.

The observed incidences revealed that time, unauthorized administration, and dosage errors were the most prevalent, accounting for 17, 10 and 18 percent of the medication errors, respectively. The observations also indicated that the errors occur during periods of high activity, for instance, during shift changes and emergency calls. The RCA also showed that staff-related causes of medication errors were attributable to inadequate pharmacological knowledge. For instance, it was observed that nurses who lacked the ideal knowledge of the ideal medication administration route were likely to cause incidences of intravenous injections. The errors were also observed to be highly associated with poor knowledge of drug pharmacological properties as well as excessive dosage. These errors were observed to be primarily caused by the complex nature of intravenous medication, which requires vast experience to deliver the drug as optimally as possible.

Notably, the nurses who made these mistakes showed a lack of in-service training among newer staff, which constrained them of the necessary knowledge to prepare and deliver the drugs. As Mazer and Nablan (2019) recommended, in-service training on pharmacology and administration of complex medicine could be an excellent approach to reducing such medication errors.

The second root cause of medication errors in the Delaware Community Clinic was a shortage of nurses, which increased the workload of nurses needed at one point in time. Interviewed nurses revealed that medication errors were highly attributable to understaffing because nurses were pressured to cover the workload. Therefore, some evidence-based solution to understaffing is employing more nurses, ensuring a smoother change of shifts, and supporting the nursing staff as much as possible (Mazer & Nabhan, 2019). For instance, during the root cause analysis, it was observed that some laboratory staff could call the physicians to collect the lab results physically. However, the results could easily be transmitted to the physician using an electronic medical records system (EMRs). Rezaei (2019) recommends that EMRs can reduce medication errors by facilitating fast, efficient, and reliable transmission of patient information between nurses, pharmacists, laboratory technicians and the patient. Using technology to transmit necessary information, such as lab reports, could help minimize the pressure that comes with physically handling the data.

Improvement Plan

The improvement plan following this RCA will take two approaches: improving staff’s skills and knowledge and making the necessary environmental changes to minimize medication errors. The first item of the plan is to improve the hospital’s medication monitoring system to improve staff coordination and enhance prescription accuracy through various cross-checking points and communication among staff. The second improvement plan will be to train the staff to prevent medication errors, especially when administering complex medications such as intravenous injections. The training should improve the nurses’ pharmacological knowledge, especially on new drugs, contraindications, dosages, and proper administration.


Medication errors are associated with lengthened hospital stays, injury, increased care costs and even death. An RCA of the factors contributing to medication errors revealed important information on some of the leading causes and their potential solutions. The report indicated that nurses’ lack of skills and knowledge, followed by poor communication and distractions, are the most common cause of medication errors. Some of the evidence-based strategies for addressing the problem include the improvement of staff skills and knowledge and making the necessary environmental changes to minimize medication errors. These two solutions will provide a ground approach to minimizing medication errors in Delaware Community Hospital.


Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14.

Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardizing the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931–939.

Ibrahim, O.M., Ibrahim, R.M., Meslamani, A.Z.A., & Mazrouei, N.A. (2020). Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes. Pharmacy Practice (Granada), 18(4), 2111.

Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper Resources:

Collaboration and Teamwork

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practicesAORN Journal102(4), 329–342.

  • Consider applying some of the communications best practices highlighted in this article to how you communicate your tool kit.

Dietz, A. S., Pronovost, P. J., Mendez-Tellez, P., Wyskiel, R., Marsteller, J. A., Thompson, D. A., & Rosen, M. A. (2014). A systematic review of teamwork in the intensive care unit: What do we know about teamwork, team tasks, and improvement strategies? Journal of Critical Care29(6), 908–914.

  • The authors discuss best practices related to teamwork and team improvement, some of which may help you think about how best to present the information in your tool kit.

Kalisch, B. J., Aebersold, M., McLaughlin, M., Tschannen, D., & Lane, S. (2015). An intervention to improve nursing teamwork using virtual simulationWestern Journal of Nursing Research, 37(2), 164–179.

  • This article presents a feasibility study for use of a simulation to improve teamwork among nursing staff.

Malamed, C. (n.d.). ;Using wikis for learning and collaboration. ;Retrieved from…

  • This article may be helpful as you think about how to put together your tool kit for your assessment.

MindTools. (n.d.). ;How to create a wiki: Setting up a collaborative online workspace. ;Retrieved from…

  • MindTools provides a practical overview of wikis, including their history and purpose, as well as how to build them.


Wolf, D. M., & Morouse, K. M. (2015). ;Using blogs to support informatics nurses’ curriculum needs. ;Online Journal of Nursing Informatics, ;19(2), 1–9.

  • This article looks at the use of blogs and other online platforms to improve learning and communication, as well as patient care.


Refer to the following links to help you build your tool kit:

Also Read:

NURSFPX4020 Capella Assessment 3: Improvement Plan In-Service Presentation

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.


NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper


Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

  • This editorial urges nurses to be active contributors to ongoing research, journals, blogs, and other outlets to increase visibility of their valuable perspectives on health care.


The Library of Congress. (n.d.). Evaluating Internet resources: An annotated guide to selected resources. Retrieved from…

  • This Web page collects resources related to evaluating the reliability and relevance of information from electronic sources. The format of this page may also be a helpful model for the resource list you are assembling.


Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

  • This editorial urges nurses to be active contributors to ongoing research, journals, blogs, and other outlets to increase visibility of their valuable perspectives on health care.

Root-Cause Analysis and Safety Improvement Plan Example

Root cause analysis (RCA) systematically and methodologically investigates an occurrence to identify the reason for a system failure that might not be apparent initially after the incident. System and personal failures can lead to patient safety risks, including medication errors (Center for Drug Evaluation & Research, 2019).

A root cause analysis was conducted to investigate an incident in the surgical postoperative unit that involved a morphine overdose. The purpose of this paper is to describe this incident, conduct a root cause analysis, and develop a safety improvement plan to prevent these occurrences in the future in the organization.

Root-Cause Analysis of Falls of Medication Errors

Charlie is a 20-year-old white female who had an emergency appendectomy three days ago due to acute appendicitis. Today, he still complains of severe pain at the incision site and the abdomen. During the review in the afternoon, his surgeon prescribed oral morphine 10mg Stat for his pain and documented that prescription in writing in the patient’s physical records. The same evening, four other patients were admitted from the operating room and post-anesthesia care unit (PACU).

RN, the day shift nurse in charge of the room, delegated the administration of morphine to a student nurse because she was attending to the new admissions. Charlie had been on IV painkillers in the first two days but showed suboptimal pain control. The student nurse picked IV morphine rarely used in the unit, and administered 10ml instead of the 10mgs prescribed by the surgeon.

The surgeon, who happened to be the head of the department of surgery, and the nurse manager in charge of the department agreed that a root cause analysis of the issue be done because there had been prior near misses in the last in the same department.

The RN discovered the issue on her hourly reviews when she noted that Charlie was becoming drowsy and confused and had vomited twice about half an hour after drug administration. The event necessitated the use of naloxone use to reverse the side effects of morphine overdose. A multidisciplinary care team was formed that monitored Charlie’s postoperative healing and recovery.

Analysis of Root Causes

The most common practice factors involved in medication errors include training, engagement, motivation, and work organization system. Interruptions commonly lead to medication errors by breaching the work organization system, thus increasing the risk of making medication errors of omission due to a break in concentrations (Schroers et al., 2022).

Possible outcomes are wrong medication, wrong dose, or wrong route in medication administration. Transitions in care provide a high risk of making medication errors. During this time, there are high chances of a break in the continuity of care, which can involve the patient medication lists.

Human factors contributing to the medication error included understaffing leading to nursing overload and delegation. The use of untrained personnel, the nurse student, to perform medication administration could contribute to the error due to inadequate competencies (Schroers et al., 2020).

Failure to double-check the prescription before medication administration led to the wrong medication and the wrong route of administration. A high patient-to-nurse ratio n could also contribute to medication errors from fatigue and burnout.

Documentation is a crucial method for interprofessional and intra-professional communication. Using manual documentation to provide prescriptions can cause medication errors due to illegible writing and confusion from lookalike sound-alike (LASA) drugs (Wondmieneh et al., 2020).

Communication is also important in medication reconciliation and double-checking the medication before administration. This could reduce the risk of medication errors in this case. Current methods of documentation utilize health technology to improve accuracy, efficiencies, and effectiveness in communication.

The nurse practice environment could also play a part in a medication error. Environmental factors such as shift and nurse staffing capacities can contribute to medication safety (Savva et al., 2022). Additional work is created for nurses in understaffed environments. This contributes to fatigue and exhaustion, which can cause medication errors.

The nurse, therefore, works to complete more tasks in a shorter time and may omit some tasks to save time. A surgical environment is a busy environment for a nurse, and completing all designated tasks can require additional speed. In Charlie’s case, poor documentation, understaffing, lack of communication, and poor care transition were the root causes of the medication error.

Application of Evidence-Based Strategies

Root causes of medication errors can be classified as personal and contextual factors. Personal factors are related to the clinician factors, while contextual factors are due to circumstances under which these errors occur. About 8%–25% of medication errors occur due to administration. About 48% – 53% of these errors can occur due to intravenous drug administrations (MacDowell et al., 2021).

In an ideal setting, medication administration should follow a sequential and controlled procedure. Practice, environmental, equipment, and communication factors contribute to medication errors related to medication administration. Shift reporting, staffing, nurse fatigue, poor communication, and interruption are the most commonly reported cause of medication safety risks.

Various strategies have been implemented in advanced settings to prevent medication errors. These strategies include but are not limited to the use of technology, medication reconciliation, interdisciplinary team collaboration, communication, and coordination (Agency for Healthcare Research and Quality, 2018).

The use of technology reduces medication errors by about 50%. Some of the technologies that have been employed to reduce, prevent and reduce medication errors are clinical decision support systems (CDSS), computerized physician order entry (CPOE), and electronic health records (EHRs).

These technologies can be synchronized in one technology system for the organization. Most importantly, clinicians must be trained on how to use these medications to enhance usability and uptake to make the process or error reduction realistic.

Medication reconciliation is an evidence-based strategy that has been documented and practiced for a long time now. However, when and where to practice medication reconciliation varies from organization to organization protocols. Performing medication reconciliation at every point of care transition makes this strategy more potent and effective.

More than 70% of medication errors are reduced when medication reconciliation is done at admission, shifting, patient transfer, and discharge (Rosenthal & Burchum, 2020). This strategy should not only be practiced by nurses but also by other clinicians.

Interdisciplinary collaboration, communication, and coordination are strategies that make other strategies effective. Without these interdisciplinary efforts, medication reconciliation and technology use can be challenging to achieve. Nurses and nurse leaders play important roles in ensuring interdisciplinary approaches through effective and timely communication and collaboration. The process of nursing care coordination sums up this strategy.

Collecting and disseminating pertinent patient information to all stakeholders can improve patient safety. This process requires assistance from technology and nursing education to make it efficient. Coordinating with the patient is also crucial so that they know what they are taking, why they are taking it, and what it can do when not taken properly. This is achieved through patient education to improve compliance and thus adherence.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The National Coordinating Council for Medication Error Reporting and Prevention definition of medication errors emphasizes their preventability (Tariq et al., 2022). Various quality improvement plans can be implemented to prevent medication errors in the aforementioned scenario.

My improvement plan for this seating will include three actions: incorporate technology in prescription, conduct bedside shift reporting, and conduct mandatory medication reconciliation at every point of care transition. As aforementioned, transitions in patient care provide the most chances for medication errors. Therefore, they can also provide the best opportunity for clinicians to prevent these errors.

Implementing CPOEs and CDSS will assist the clinician with prescription and decision-making by providing alerts and warning for potential medication safety risks. These technologies also provide clinicians with platforms for communication and collaboration. They will make the process of interdisciplinary collaboration and coordination efficient.

The last part of the plan is to implement bedside shift reporting to provide an opportunity for medication reconciliation. Handing over at the patient’s bedside will enhance care collaboration that will also be patient-centered, thus lowering the risk for patient safety concerns.

This plan aims are preventing future medication errors and empower interdisciplinary participation in the unit through the three strategies. Expected outcomes include reduced patient medication adverse events, improved patient satisfaction, reduced patient stay, and improved patient-centeredness in care. Implementation of the plan will adopt a PDSA cycle process for projects. Completion of the first cycle can take about three months, and regular monitoring and evaluations will be conducted to ensure project effectiveness.

Existing Organizational Resources

Implementation of the above quality and safety improvement plan will require human and technological resources. While it aims at solving the human shortage at the same time, this plan will require the human skills to actualize the technological plans. A health information system will be the first essential resource for plan implementation.

Human resources that would be required include nurse informaticists and healthcare system technologists. An electronic health information system is required to support various technologies that would be implemented to actualize the project plans. Existing resources in the organization include human resources and electronic health records.


The medication safety issue involved a young adult, a postoperative patient, who received a morphine overdose jeopardizing his safety. Root cause analysis revealed various root causes of medication safety: poor communication, understaffing, and poor care transitioning. Evidence-based literature has documented the above causes, either personal or contextual. Medication administration has been a significant source of medication errors.

Strategies to reduce these errors have included medication reconciliation, health technology use, and interdisciplinary teams. Communication, collaboration, and coordination have been effective in patient safety risk reduction. The quality improvement plan to address the issue included implementation of CDSS, using CPOE, and implementing bedside shift reporting. Human resources and electronic health records are vital resources that will be required to actualize this plan.

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper References