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

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

Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. (CAMH, 2016) The issue explored in the following essay will be medication errors and how they can be prevented. Medication errors are a leading causative factor for sentinel events in hospitals and nursing homes. Root cause analysis highlights these events and subsequently allows hospitals and nursing homes to implement changes to these risk factors, which prevents these issues from repeating. These sentinel events can lead to casualties from major damage to the death of a patient, depending on the severity. There is no one factor to prevent medication errors; this domino effect of various causative factors plays a role.

Sentinel Event

The event involves a medication administration error that happened after a travel nurse administered the wrong packets of medications to the wrong patient during the morning medication pass. The particular travel nurse had been given minimal orientation to the unit, and there was minimal staffing. A floor of 3 nurses and 2 PCA to provide care for 45 patients was subjected to 2 nurses and 1 PCA (patient care associate). The quandary occurred during COVID-19. This locked psychiatric hospital unit was quarantined after the patients residing in this unit, was tested positive for the COVID-19 virus. The regular protocol of the unit, where these alert and oriented mentally ill patients would walk up to the nurse’s station for their medications, was now subjected to room isolation for quarantine. This unit of patients also does not wear name bands. Instead, they verify their identity by their MRN (medical record number) number and date of birth. A photo image of the patients is also displayed in the left-hand corner of the monitor for extra security of identification. The medications are held in a patient medication drawer system which is filled by the pharmacy once a week unless a new order is placed, in which a pharmacy technician would walk over the medication to the unit. The medications should be arranged by room number instead of alphabetical order to prevent errors such as this, at least while they are in quarantine.

Another travel nurse who was more familiar with the unit caught the mistake after walking in with medication for the correct patient and observing the wrong patient swallowing the wrong medication. The patient was immediately observed for observation. Over the course of the day, the alert and oriented patient was observed to be somnolent and less alert than normal. This patient also was asymptomatic from the COVID-19 virus. The patient had received a series of Schizophrenia medications with an entirely different diagnosis, along with a benzodiazepine which the patient wasn’t taking, HTN medication, which was of different strength, and HIV medications, for which the patient was not positive. The physician was immediately notified, and the patient was placed under intense observation. Q (every) 15 minutes vital signs x 1 hour and Q (every) 30 for 3 hours. Labs were drawn for BMP, CBC, AST/ALT, Depakote toxicity, and kidney and liver function. His condition deteriorated after he went from somnolent to disoriented and less responsive. By the afternoon, the patient was only responsive to tactile and pain stimuli like sternal rubs and pinching of the skin. The patient was placed on the oxygen of 2 liters, BiCarb, Normal Saline, and Levophed IV for soft BPs and MAPs. After several hours, ultimately, the patient ended up returning back to baseline the next day and was placed on 1:1 observations for 7 days.

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

Analysis Of The Sentinel Event

These mistakes occur very often in healthcare facilities, from nursing homes to hospitals, of all qualities. Although the patient returned to normal, this unique situation placed the unfamiliar nurse in a very dangerous situation. However, the Five Rights of administration (Right drug, dose, route, patient, and time) were also discounted due to the isolation of patients. The uncertain nurse should have made a better effort to determine the identification of the patient by asking the patient to confirm his date of birth or by asking a staff member on the floor who was more familiar with the unit. Disorientation can occur in ill patients, especially with the COVID-19 virus. According to Grissinger RPh, (2014), explaining the medications to oriented patients, showing them the packaging, and telling them the name of their medications are also good practices for preventing medication errors. Sedatives, such as chloral hydrate and benzodiazepines, are commonly given for procedural sedation and during hospitalization. Inappropriate use can lead to oversedation, lethargy, hypotension, and delirium. (Anderson MSN RN, 2015)

A regular staff member familiar with the unit should have been assisting with directions to the unfamiliar nurses during the med pass, especially if and when the patients are not required to wear name bands for scanning and identification. Name tags should have also been implemented and placed over the patient’s bed for identification during the quarantine to prevent such issues. A lot of hospitals are understaffed on their units, and the patients suffer. Growing shortages of nurses are causing staffing problems throughout the industry, including the well-known dilemma of chronic understaffing, which makes covering open shifts a constant scramble. The resulting long hours and overwork can lead to increased medical errors, eroded staff morale, reduced patient satisfaction and outcomes, and, eventually, higher costs. Temporary nurse staffing can be part of the solution. (Faller Phd, RN 2019) Dividing the workload equally amongst nurses and PCAs creates a healthier working milieu. It prevents mistakes because the nurses have time to double-check before creating errors. Tired, overworked employees are likely to call out and/or make more mistakes than a more alert and well-rested employee. Travel nurses are employed to fill in the gaps of their shortage but are given little orientation and are not acclimated to the culture of the hospital or nursing home.

Safety Improvement Plan

Based on the outdated plan of medication dispensing, it would be beneficial for this particular psychiatric hospital to implement a better system, such as a computerized barcode medication system. While traveling to previous hospitals, I’ve seen the Omnicell automated barcode medication system, where the medication comes individually wrapped with the patient’s name, date of birth, and MRN already programmed into the computer. The Omnicell system is also equipped with a scanner to scan the patient’s bracelet, which electronically communicates with the medication and personal information previously scanned. This leaves no room to give medication to the wrong patient. A medication barcode system is essential in this organization. The number of patients housed in this hospital without proper precautions taken while administering medications, especially with travel nurses, leaves room for a myriad of medication errors.

The barcode medication system also optimizes the time spent administering medications leaving more room to do different activities with impatient or mentally ill patients. Every patient Should have some sort of identification for medications, tracking, and safety. Post implementation; the hospital would be able to see a significant decrease in incident reporting due to medication errors within months. There would be a level of consistency with medication passes and timing. Nurses would be able to finish heavy medication passes in a timely fashion, leaving fewer physician orders for a patient time extension. This would also provide better communication between the pharmacy and nursing to deliver medications before the patient slot is emptied.

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

Existing Organizational Resources

Because most psychiatric hospitals are state-funded, financing the barcode medication system should be easier to implement for the safety of the mentally ill. The Director of Nursing, the finance department, and compliance nurses will have to work as a team to advocate for an advanced medication administration system. The Joint Commission National Patient Safety goals state that there have to be two unique patient identifiers, and it’s imperative the staff match the /medication/treatment to the individual patient (The Joint Commission, 2020). They must present the amount of medication incident reports written in the past couple of years to support their dire need for change. They must also compare the amount of money they are throwing away due to medication errors to the money being saved. Because patient safety is the goal of healthcare agencies, reporting should be encouraged. Information from these reports should be shared and published across the entire organization and presented to the state to prevent future errors and support their argument. The patient nearly lost his life due to the hospital’s ancient policies in place.


In conclusion, medication errors continue to be a serious issue in healthcare settings. Although there are many avenues that are in place to prevent such occurrences, many facilities have not come to date to implement them. Many systems in place may prevent medication errors due to the consistency or routine of familiar staff, but when the “regulars” are absent, it causes an immense problem putting patients at risk for harm. But medication administration isn’t a routine performance; it is a serious task performed by nurses for the patient’s health, safety, and well-being. This root cause analysis was performed at a State Psychiatric Hospital in New York. Causative factors for wrong medication, wrong patient, lack of communication, and lack of identifiers. The Joint Commission guidelines, which expect to present two identifiers, such as name and date of birth, were violated. The goal of implementing an improvement plan for medication errors is to develop options to improve and enhance safety and reduce the risks and occurrences that our patients experience daily due to gaps in the system. In this essay, I presented evidence-based evidence from a personal situation related to the risks of medication errors. The improvement plan includes better communication, better nurse staffing for healthy nurse-to-patient ratios, patient identification such as name ID bracelets, and a medication barcode system.

See Also: NURS-FPX 4020 Assessment 3 Improvement Plan In-Service Presentation


Anderson MSN RN, APRN-BC, CCRN, & Townsend MA RN, CCRN-CMC, T. (2015). Preventing high-alert medication errors in hospital patients. American Nurse Today, 10(5), 18–22.

Faller Ph.D. RN, M. (2019, January 22). Temporary Nurses: A Viable Solution to Nurse Shortages. hfma featured.

Grissinger, M. (2010). The Five Rights A Destination Without a Map, 35(8),

Grissinger, M. (2014). Oops, Sorry, Wrong Patient! A Patient Verification Process Is Needed Everywhere, Not Just at the Bedside, 39(8), 535–537.

JE; R. L. H. B. H. (2021, January 4). Medical Error Reduction and Prevention. National Center for Biotechnology Information.

Joint Commission Resources. (2016). Comprehensive accreditation manual: CAMH for hospitals Sentinel Events. In Comprehensive accreditation manual: CAMH for hospitals (pp. 3–18).

The Joint Commission. (2020, March). National patient safety goals are effective July 2020 for the hospital program [PDF]. goals/2020/npsg_chapter_hap_jul2020.pdf

Shah, K., Lo, C., Babich, M., Tsao, W., & Bansback, N. J. (2016). Bar code medication administration technology: A systematic review of the impact on patient safety when used with computerized prescriber order entry and automated dispensing devices. The Canadian Journal of Hospital Pharmacy, 69(5).


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For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

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