3 1 Root-Cause Analysis and Safety Improvement Plan School of Nursing and



Root-Cause Analysis and Safety Improvement Plan

School of Nursing and Health Sciences, Capella University

NURS4020: Improving Quality of Care and Patient Safety

Erica Elkins-Little


Root-Cause Analysis and Safety Improvement Plan


           Different events occur in the nursing profession, and if an error occurs in the medical administration, it will be a significant issue. It is essential for the nurses to consider the medication errors and to observe whether they are giving the proper medication to the patient. Last week, a mistake in medical administration occurred, and it was the worse situation. The senior nurse was on duty and the junior nurse signed off by completing her shift. One of the patients suffered from high blood pressure and hypertension and started vomiting. The patient was bitterly vomiting while he was on high fever, and there was no issue of nausea and vomiting since his admission to the hospital. 

Analysis of the Root Cause

The event has already been explained that a patient started vomiting in the hospital, and it was continuous vomiting. The patient was o high-grade fever, and there was no link to vomiting with the patient. The junior hospital assistant detected the problem and called the senior nurse to the duty, and it was a moment of tension for the patient and his family. The nurses noticed that the wrong medication caused the problem. Acetaminophen is the patient’s allergic drug, and the junior nurse did not tell the senior nurse of the patient’s allergy. The nurses’ negligence led the patient to face the issue.

           It was supposed to happen that the senior nurses needed to ask about all the patients and their conditions. The junior nurse had to inform the old nurse of the patient’s allergy. The environmental factors could not play an essential role because no one was in the patient’s room. The resource factors or equipment did not have any influence. Human errors and communication played a crucial role in the patient’s situation because it was found that the wrong administration of medication caused the issue.

Application of Evidence-Based Strategies

There are many strategies to address the wrong medication. The nurse should update the incidence reporting system to ensure that the patients, their families, or the hospital staff must inform the relevant doctors or nurses of the issue. It was impossible to address the incidence reporting issue in the current event because the error had already occurred. It was important for the nurse to remove the IV because the medicine was given through the route. The patient was given the medication to overcome nausea and vomiting. The patient was given saline water (Sonğur, 2018).

Several other strategies can overcome the wrong medication, including effective communication and coordination. Most of the cases have observed that the medication errors are because by human errors and mistakes. The nurses could not communicate with one another effectively.

In the current scenario, the senior and junior nurses did not have the proper communication because the errors occurred. It was important for the hospital administration to encourage the nurses to communicate thoroughly before leaving. The nurses should read the prescription paper before giving any medication to the patient.

           The literature is full of such incidents and the strategies where the communication strategies were ineffective and the nurses could not manage. The nurses need to communicate well and ensure the patients’ proper medication. If the patients are not given the appropriate medication, there will be negative consequences on health. So, the right medication is necessary.

Improvement Plan with Evidence-Based and Best-Practice Strategies

           Some different strategies and policies are used to address the wrong medication. Medication errors have become a common debate in the literature, and the nurses are found to be responsible for them. Most of the time, the nurses do not communicate properly with their colleagues and cannot handle the matter. The wrong medication is primarily the result of miscommunication and an inefficient reporting system. The wrong medication can be addressed through different strategies. These strategies are national or international level, and it is seen that the medical errors are almost similar (Klingbeil, 2018).

           The first strategy or the policy of wrong medication is the right person, the proper medication, and the correct dose. The exemplary method and right timeline are also included in the strategy and policy. The nurses need to ask one another, or if the relevant nurse is not available, it is good to consult the doctor before the medication. If the proper medication is not given, the situation can be worse. The correct patient and right dose are essential because the right dose is necessary. Otherwise, the worse consequences can occur. The nurses need to improve the reporting incidence system in the hospital as well.

           If we analyze the current scenario, it can easily be seen from the situation that the nurses have miscommunication, and it was a human error. The hospital should initiate the new policies for the nurses and other staff members to ensure proper communication and help the patients recover as early as possible. one of the most important things that the nurses have to improve is the incidence reporting system. The proper training will enhance the incidence reporting system (Hong, 2019).

           The training will help the patients and the nurses to have care coordination. The medical errors will be reduced, and the communication gap will be minimized. All these strategies will help in the better results.


Existing Organizational Resources

           The initiative should be taken to improve the communication among the nurses, and it is essential to reduce medical errors. The nurses are usually involved in medical errors, and it is observed that different existing and new resources are needed to accomplish the plan. The plan will be implemented within two months. Additional steps are required for the organization, which will help improve the medication error (Härkänen, 2018). 

           The existing resources are the laptops and computers that will integrate the technology with the patients. The nurses will have to compile the records of patients on the computer so the coming nurses may see the data. There should be an incidence reporting system already linked with the software. So, there is no need for more resources, but the existing resources will be enough. Moreover, it is essential to improve the nurses’ communication skills, and the training sessions will be arranged for them. Communication is the strength of the hospital organization because the nurses will better understand one another, and the medication errors will be reduced (Costa, 2021). 


           In conclusion, it is seen that medical errors are most common in hospitals, and they involve the nurses. Nurses need to overcome the issues of medical errors. Different strategies will be overcome through the various methods and policies discussed above. All the plans will be helpful and will be better for the hospital administration in the future. 


Costa, C. R. D. B., Santos, S. S. D., Godoy, S. D., Alves, L. M. M., Silva, Í. R., & Mendes, I. A. C. (2021). Strategies For Reducing Medication Errors During Hospitalization: Integrative Review. Cogitare Enfermagem, 26. https://doi.org/10.5380/ce.v26i0.79446.

Härkänen, M., Blignaut, A., & Vehviläinen‐Julkunen, K. (2018). Focus group discussions of registered nurses’ perceptions of challenges in the medication administration process. Nursing & Health Sciences, 20(4), 431-437. https://doi.org/10.1111/nhs.12432.

Hong, K., Hong, Y. D., & Cooke, C. E. (2019). Medication errors in community pharmacies: The need for commitment, transparency, and research. Research in Social and Administrative Pharmacy, 15(7), 823-826. https://doi.org/10.1016/j.sapharm.2018.11.014.

Klingbeil, C., & Gibson, C. (2018). The teach-back project: a system-wide evidence-based practice implementation. Journal of Pediatric Nursing, 42, 81-85. https://doi.org/10.1016/j.pedn.2018.06.002

Sonğur, C., Özer, Ö., Gün, Ç., & Top, M. (2018). Patient safety culture, evidence-based practice, and performance in nursing. Systemic practice and action research, 31(4), 359-374. https://doi.org/10.1007/s11213-017-9430-y.