NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

This adverse event affected Hannah, her family, the organization, and the nursing staff. The patient’s recovery period was extended, and she had to undergo further procedures to control her bleeding. Moreover, her healthcare expenditures increased, and family members were distressed seeing her endure pain all over again. Healthcare organizations faced problems as their healthcare costs were further ameliorated due to additional treatments. The nursing staff was struck with fear and sadness as their poor attention toward patient care led to significant incidents, posing safety risks to patients’ lives. The root causes identified in this particular scenario were as follows:

• Wrong Medication: The nurse administered the wrong medication, heparin instead of morphine, without double-checking or reading the label attentively before administration to the patient.
• Non-Serious Attitude: The nurse exhibited a non-serious attitude and took phone calls while performing her duty and dealing with the patient’s life.
• Non-Adherence to Medication Administration Protocols: The nurse did not implement the medication administration protocols, such as double-checking before administration, following the five rights of medication administration, and reading the medication label correctly.
• Poorly Maintained Equipment: The automated dispensing system dispensed the wrong medication, and the healthcare organization did not pay attention to its adequate maintenance.

The RCA revealed these underlying causes, which contributed to the onset of the unfortunate adverse event. Considering these root causes, medication errors in the future can be prevented. Moreover, patient safety can be enhanced by implementing strategies that solve the above-mentioned issues.

Application of Evidence-Based Practice Strategies

 After conducting a thorough root-cause analysis, it is crucial to implement evidence-based strategies considering the underlying causes of medication administration errors at TGH. These evidence-based strategies can improve patient safety and reduce medication errors. Moreover, they will reduce the costs incurred by patients and healthcare organizations. One study shows that about 62.1 % of nurses make medication errors due to a lack of training on safe and effective medication administration (Wondmieneh et al., 2020).

Another study finds that external interruptions during medication administration, such as bedside conversations and taking phone calls, account for 18.8 % of medication errors (Manias et al., 2021). Another study highlights how healthcare information technologies also lead to medication administration errors due to poor maintenance and flaws in designing the technology to mitigate human errors (Ambwani et al., 2019). 

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

The best practices include training nurses on safe medication administration, where nurses can be educated on protocols regarding medication administration. Nurse leaders can play a vital role in training young nurses on the five rights of medication administration and how this strategy can address medication safety issues. As the five rights of medication administration include the right patient, the right drug, the correct dose, the right time, and the right route of administration, nurses can prevent medication administration errors due to the wrong medicine and the wrong patient (Manias et al., 2021).

Moreover, healthcare organizations can integrate a new technology of medication administration, i.e., Bar Code Medication Administration. This will enable double-checking with accuracy through barcode scanning of the label on the drug and matching it with the barcode mentioned on the patient’s bedside or wrist. This will ensure the patient is acquiring the medication prescribed to him with the help of Barcode (Owens et al., 2020).

Healthcare organizations can revise policies for nursing staff to carefully provide care treatments to patients and avoid external interruptions such as bedside communications, distracting conversations, and taking unnecessary phone calls. Any violation of these policies should instigate disciplinary actions and penalties. This will enhance a culture of careful administration of drugs without external interruptions (Yang et al., 2022).

 Evidence-Based Safety Improvement Plan 

Considering the alarming situation of TGH, where medication administration errors impact patients’ safety, developing a safety improvement plan for safe medication administration is imperative. This improvement plan accounts for the factors contributing to patient safety risks and can potentially lessen