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

NURS FPX 4020 Assessment 2 Attempt 1 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

In this assessment, we will apply the root-cause analysis and safety improvement plan, where the main issue and its reasons will be discussed in depth. Defining root-cause help in building the structure for improvement of patient safety and medication administration in an organization. Furthermore, the appropriate strategies will also apply to address the issues or sentinel events about medication administration. The assessment will help us find the defined issue’s improvement and safety plan while penetrating the existing organizational resources (Bates & Singh, 2018).  

Analysis of the Root Cause

Medication errors or medication administration errors are most common type of errors that occur in a hospital. In the United States, each year, many hospitals face the allegation of prescribing or injecting the wrong medication to the wrong patients. Similarly, the incident occurred in the St. Luke Magic valley. They faced a huge disruption due to their medication error in which the nurses mistook the adult’s patient medication for the infant’s medication and infused the infant with cardiac medication. This medication administration error caused the child’s death after 10 minutes of injecting the medicine. Losing one life can be a real threat to the hospitals and an unbearable loss for the families (Prentice, 2020).   

Hence, it is essential to figure out what went wrong and what made the situation worse. Proper investigation is required to find out the incident’s root cause and help organizations prevent such incidents in the future. This medical malpractice was performed by the St. Luke’s Magic Valley Regional Medical center, and the reason was a lack of consideration and losing focus to double-check the medication. In the investigation, the nurses explained that the medication bags were similar with different labels, which made the nurse believe that the medicine was for an infant without double-checking the label. This incident happened at night at almost 11 pm, and most of the staff were off-duty due to staff shortage, the nurses in the nurse station were occupied with labeling medicines for the medication (Gates et al., 2019). During the process, one nurse took a medicine bag from the nurse station that was prepared for the adult patient, especially for a cardiac while on the other side; the infant also had heart disease, so due to similar bags, the nurses administrated the adult’s medicine to the child. This malpractice caused a huge loss for the family due to the hospital’s liabilities. They agreed that the nurses played their duties poorly and lacked ethical codes and communication, which led to the unbearable loss (Koyama et al., 2019). 

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

Application of Evidence-Based Strategies

After the incident, the hospital management and authorities took serious action and admitted their mistakes of being so unprofessional and unethical. They stated that they missed the standard procedure for administering medication, and they are deeply regretting the loss. The authorities also claim that they imposed better strategies and guidelines after the accident and tightened their process to mitigate the chances of human error in the near future. 

Some best practices were considered to address the safety issues or sentinel events regarding medication administration, such as the implication of barcode systems and medication preparation for one patient at a time. Because of workload and understaffing, the nurses were so busy preparing different medication bags in the nurse station that to forget to double-check the medication administration. Planning for medication administration to avoid malpractices is necessary; otherwise, the hospitals would encounter safety issues (Tariq & Scherbak, 2021). 

The implication of the Barcode Medication Administration System (BCMA) will also help nurses to provide the right prescribed medicine t the right patient despite their busy schedules (Zheng et al., 2020). The Barcode system will analyze the detailing of the medication, such as expiry date, patient information, medication information, and most importantly, the selection of the right medication bag. Smart infusions, single-use medication packages, and pumps for intravenous administration (IV) are some strategies to enhance patient safety issues related to medication administration. Implementing these strategies will reduce human error despite being exhausted, busy, or unfocused. These systems will take care of patients and help the organizations save themselves from such patient safety issues with unbearable losses (He et al., 2019).

Furthermore, improving the communication system and providing the staff with proper guideline templates will help them embrace the organizational ethical codes to avoid disruption in the system. An effective communication system will also lead the staff towards team engagement and a prosperous working environment because understanding roles and responsibilities is crucial for staff to consider. Moreover, the hospital should not neglect the understaffing issue that causes the nurses to burn with the workload. So, recruiting skilled and efficient people would be the organization’s need to reduce the workload burden on nurses and avoid them being burnt out (Garcia et al., 2019). 

Improvement Plan with Evidence-Based and Best-Practice Strategies

Planning is a crucial process to implement any important strategies; similarly, as we suggested, some of the best-practices strategies and techniques to avoid medication malpractices, so for this purpose, having a proper plan is required. The strategies of implementing the technological system and imposing guidelines can only be reassured with the proper plan. To improve the communication system between medical practitioners and nurses, it is required to have a platform to communicate, such as an application that is accessible for staff only and where they can discuss the daily chores or the medication details if they have any misconceptions about mispronunciation (Fisher & Kiernan, 2019). 

Team building and engagement is also crucial step, and they should be promoted by implementing a respectful environment. The leaders should articulate the achievable mission and vision plus define the team roles and responsibilities so that everyone must be aware of their tasks and perform exemplary. For example, the leader in the organization must apply the functions and duties with their name on the notice board so that everyone can read from there and acknowledge their responsibilities. It will create a safe space and promote team building (J. Weaver et al., 2018).  

The plan will include many aspects, such as improving communication, implementing technological systems, and encouraging the staff to embrace the change and work accordingly. The first aspect of communication can deal with providing efficient resources such as platforms and improved leadership skills that motivate employees to work hard despite night or day shifts (Di Simone et al., 2018). 

The total quality management (TQM) system can be used for the other aspect of the plan where technological involvement is required. The TQM approach will work with the six sigma rule, ensuring the system’s quality and safety at their peak (Trakulsunti & Antony, 2018). This approach will reduce human errors and cause the organization to face fewer medication malpractices. The Technologies such as the barcode system and IV system will be ensured through the six sigma rule that defines the system’s quality and capability so that the authorities can trust and motivate the staff to utilize it to improve their performances and system efficiency. 

The plan on applying technology systems will make the nurses aware of administering the right bag to the right patient and not facing the same accident due to staff shortage or exhaustion. The hospital should consider nurses’ health and routine and provide efficient staffing to monitor the patients with complete consideration, plus double checking the patients’ doses and name labels (Trakulsunti & Antony, 2018). 

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

Existing Organizational Resources

Plans and implementation depend on the existing organizational resources and the organization’s capability to attain enough resources to provide patient safety measures. The first aspect of the plan will be implementing a better communication system, which requires a platform to communicate, such as any application accessible by the internet and restricted to staff only, requiring IT department expertise and appropriate budgeting. To overcome the burden, the hospital should recruit new skilled and expert people, so the HR department must consider this issue and hire advanced nursing practitioners to balance the workload (BU Mueller et al., 2022).

Furthermore, implementing technology and assessing the quality through the six sigma approach requires quality assurance assistance with strong command. The technologies must be approved by the quality assurance system (QA), and risk assessment department, and implemented in the hospital to improve patient safety. However, all these measurements required appropriate budgeting and costs to ensure the safety measures. The HR, IT, and QA departments are already involved in the system, so these existing resources should coordinate well with the administrators and manage the budgeting costs while providing best practices for the medical administrations (Bates & Singh, 2018).  If the impact is prioritized, the HR department will have maximum impact as they hire or fire any healthcare practitioner. Medication administration errors are no joke. They can cause a hospital to lose thousands of dollars. Hence, hiring carefully is essential.


Hence, the regrettable incident in St. Luke’s Magic Valley Medical Center caused the authorities to take severe decisions and adequately implement them. We first analyze the root cause of the accident: the staffing shortage, nurse exhaustion, poor consideration, and focus, lack of communication and team engagement, and lack of resources. After understanding root-cause, we initiated the strategies and best practices that could lead us toward the betterment of the hospital and mitigate the allegation of poor coordination. For this purpose, we offered some technological instruments to help us provide the best patient safety assurance and engage the staff to perform better. However, we also considered the implementation plan for these strategies and looked upon the organization’s existing resources to improve the medical administration and reduce the medical malpractices in the organization.  

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


Bates, D. W., & Singh, H. (2018). Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. Health Affairs, 37(11), 1736–1743.

BU Mueller, W Franklin, ERS Fisher, & DR Neuspiel. (2022). Principles of Pediatric Patient Safety: Educating Harm Due To Medical Care.

Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal of Critical Care Medicine, 22(5), 346–352.

Fisher, M., & Kiernan, M. (2019). Student nurses’ lived experience of patient safety and raising concerns. Nurse Education Today, 77.

Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicine, 55(9), 553.

Gates, P. J., Baysari, M. T., Gazarian, M., Raban, M. Z., Meyerson, S., & Westbrook, J. I. (2019). Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis. Drug Safety, 42(11), 1329–1342.

He, J., Baxter, S. L., Xu, J., Xu, J., Zhou, X., & Zhang, K. (2019). The practical implementation of artificial intelligence technologies in medicine. Nature Medicine, 25(1), 30–36.

Koyama, A. K., Claire-Sophie Sheridan Maddox, Li, L., Bucknall, T., & Westbrook, J. I. (2019). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety, 29(7).

Prentice, G. (2020). St. Luke’s: Nurse’s Medication Error Resulted in Child Fatality. Idaho Press.

Tariq, R. A., & Scherbak, Y. (2021). Medication dispensing errors and prevention.; StatPearls Publishing.

Trakulsunti, Y., & Antony, J. (2018). Can Lean Six Sigma be used to reduce medication errors in the healthcare sector?

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2020). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5).

  1. Weaver, P., Sallie J., Rosen, A. Diaz-Granados, M., Dietz, D., S. Benishek, A., E. Thompson, L., & Pronovost, D. (2018). APA PsycNet.

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