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Root-Cause Analysis and Safety Improvement Plan

Root-cause analysis (RCA) is a systematic strategy for solving problems and issues that cause significant destruction in any organization. Healthcare organizations use this strategy to resolve various issues, including preventable adverse events such as medication administration errors. The prevailing medication administration errors called for immediate action of RCA to lessen medication administration errors. This paper will highlight the use of RCA in Acadia General Hospital (AGH), where medication administration errors critically impact patient safety. Moreover, the assessment will discuss the root causes of recent medication administration errors in AGH, apply evidence-based practice strategies, and craft a safety improvement plan. Lastly, it will highlight identified existing resources of AGH that could be leveraged to improve safety improvement plans for safe medication administration.

Analysis of the Root Cause

Several medication administration errors occurred at AGH, but the incident of medication administration error due to the wrong medication by Jenna instigated the RCA. Jenna was a nurse on duty in the medical ward; on her evening round, she found that one of her patients, Graham, who complained of arthritis pain, required a dose of “Celebrex.” The nurse retrieved the wrong medication, “Celexa,” instead of “Celebrex”  due to lack of attention and being mentally absent during dispensing. Additionally, the question arises if the ward environment was chaotic or if there were distractions that could have contributed to Jenna’s mistake.

Moreover, she did not double-check the medication before handing it to the patient. Graham took the medication without knowing that it was the wrong medication. It is essential to probe if there was a breakdown in communication between Jenna and Graham or if the patient was adequately informed about the medication he was receiving. The nurse found the mistake when investigating the medication administration chart and immediately reported to the healthcare team to manage Graham’s condition. Fortunately, the patient did not suffer any severe side effects of the anti-depressant agent to stabilize mood.

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

This error could have been prevented if the nurse exhibited attentive behavior and mindful performance during medication administration. The negligent behavior toward crucial tasks like medication administration was the primary cause of this incident. Moreover, the nurse did not comply with the medication administration protocols and required further education and training on safe medication delivery. The situation calls for evaluating whether communication between the medical staff, particularly in relaying and verifying medication instructions, was effective and transparent. When nurses show inadequate attention and mindfulness attitudes, these errors occur frequently, particularly for sound-alike and look-alikes medications (Schroers et al., 2020). Furthermore, the lack of technology-based medication administration further results in medication errors. The presence of healthcare information technology can alleviate the incidences of these errors. 

Application of Evidence-Based Strategies

The literature addresses numerous factors that lead to safety issues during medication administration. One study states that out of 185 nurses, 24 engaged in medication administration errors due to a lack of training on safe medication administration (Wondmieneh et al., 2020). Therefore, healthcare organizations must implement evidence-based strategies. One of these strategies includes training nurses on mindfulness during medication administration procedures. The literature substantiates this strategy, as 73.3% of medication errors are reduced by training nurses on mindfulness and attentive behaviors (Ekkens & Gordon, 2021).

Another strategy includes integrating barcode medication administration (BCMA) technology to avoid medication administration errors due to wrong medication. The barcode will identify and confirm that the medication administered is correct and matches the one prescribed to the patient. This will result in enhanced patient safety and reduced incidence of medication administration (Mulac et al., 2021). Lastly, developing protocols on medication administration within hospitals can reduce medication administration errors as nurses will be held accountable in case of any violations of those protocols. Nurses will be more focused on implementing the protocols and relevant policies on medication administration due to the vulnerability of losing their jobs, heavy fines, and litigation actions (Vaismoradi et al., 2020).