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Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Today, patient safety necessitates continuous changes supported by evidence to eradicate flaws in the healthcare system. For this paper, the issue that the root-cause analysis will explore is the wrong medication dosage. The event occurred in the ward of a hospital where I worked in the past, where a nurse administered the wrong insulin dose. This paper analyzes the root cause of the issue, evidence-based strategies to address the issue, an evidence-based safety improvement plan for safe medication administration, and organizational resources that can be used to improve a plan for safe medication administration.

Analysis of the Root Cause of the Patient Safety Issue

The issue arose when a nurse administered 200 units of Lantus to a patient just before the end of her shift. It was detected by a nurse on the next shift when doing regular blood sugar checks on patients on antidiabetic medications. The nurse found the patient’s blood sugar levels to be 49 mg/dL. In this case, the patient was affected as she ended up becoming hypoglycemic. The hypoglycemia was solved by administering D50 to the patient. After talking to the nurse who had helped the patient with the insulin, the nurse said she had helped 200 units of Lantus insulin. However, it was later discovered that she was supposed to assist 20 units instead of 200. The nurse also stated having been interrupted by two patients while administering the medication. The pharmacist had misread the order and transcribed it onto the medication administration record as “200 units Lantus every 24 hours” instead of “20 units Lantus every 24 hours”. However, when the handwritten order from the physician was checked, it was found that the physician’s handwriting was not clear, and one could quickly think he had written 200 rather than 20. The pharmacist was asked if he had asked the physician about this for clarification, and in response, he said the physician had neither indicated his name nor his phone number on the medical order. Therefore, in this case, the environmental factor that might have contributed to the error was an interruption, as the nurse was interrupted by patients, thus failing to realize that the dose she was administering was too high. There was also a human error of illegible handwriting from the physician since one could not easily conclude that he had written 20 and not 200.

Application of Evidence-Based Strategies

Several evidence-based strategies can be used to solve medication errors related to administering the wrong dose of a medication. Interruptions have been cited as one of the significant causes of medication errors. In a study by Johnson et al. (2019), where there were interruptions in 99% of medical events, it was found that a clinical error was reported in 3.6% of the events. The most common medication error caused by interruptions is the wrong dose of medication. As shown by Kellogg et al. (2021), of all the medication errors that interruptions can cause, the wrong dose is the most common, accounting for 14.4% of all medication errors. Illegible handwriting is also a common cause of medication errors. Bhutada (2020) found that illegible handwriting is linked to 44.1% of transcription errors. The transcription errors are mainly related to the name, dose, and frequency of administration of drugs.

Medication errors caused by interruptions can be minimized by having separate rooms for medication preparation and administration. Huckels-Baumgart & Manser (2021) showed that having a separate room for medication preparation and administration reduces the rate of medication errors from 1.3 to 0.9 per day. Another strategy could involve using ‘do not interrupt’ vests. This can alert patients and other healthcare professionals that nurses are engaged in a meaningful activity and should not be interrupted. Schutijser et al. (2019) found this intervention effectively reduces medication errors.

Other strategies to mitigate the issue of administration of wrong doses of medications can be based on handling the problem of illegible handwriting. Computerized pharmacy order entry (CPOE) prevents errors caused by illegible handwriting from physician orders. It reduces medications that would have been caused by poorly handwritten names of drugs, dosages, frequencies, and abbreviations. In addition, using CPOE can help facilitate communication between healthcare professionals. This is achieved using a system where all healthcare professionals can put their names and contact information on medical orders (Moudgil et al., 2021). The presence of contact information on medical orders can make communication easier in case some issues may require clarification.

Improvement Plan with Evidence-Based and Best-Practice Strategies

To reduce the rate at which medication errors occur at the hospital, it would be necessary to implement CPOE. The CPOE has been shown to minimize medication errors, as Moudgil et al. (2021) demonstrated. The use of this system would help reduce the use of handwritten medical orders. As a result, all medical orders from physicians would be electronic. The CPOE would be designed in such a way that it meets all the medical ordering needs of doctors. It would have unique features such as providing essential warnings and reminders, correct dosing schedules, scanning for potential drug interactions, comparing new and current orders, and a summary of orders issued.

Moreover, the CPOE would allow for communication between healthcare professionals as the names and contact information of anyone who makes a medical order would be indicated. The system would be developed in two months and tested for one month before implementation. On implementation of the system, one desired outcome would be reducing medication errors caused by handwritten medical orders to less than one error in a day. This is an achievable outcome, as it was found by Khalil et al. (2020) that a CPOE can reduce medication errors by 48%.

As part of the improvement plan, it would also be necessary to carry out simulation-based training that would help minimize medication errors. Sarfati et al. (2019) show that simulation-based training can integrate human factors to reduce medication errors. The training would be done during the testing phase of the CPOE. It would involve all healthcare professionals working at the hospital. Selected individuals working at the hospital would be requested to act as simulated patients. This would be followed by a simulation of all activities at the hospital from when patients are admitted to when they are discharged. All healthcare professionals would be provided with a list of activities they need to do to minimize medication errors. There would also be a simulation of scenarios that lead to medication errors, such as interruptions. The simulation-based training would be carried out after one month. It would only take either a morning session or an afternoon session. By the end of the training, all healthcare professionals must be conversant with the activities they must do to minimize medication errors. It would also need to know how to handle situations that can lead to medication errors.

Existing Organizational Resources

Hospital administrators would be required to provide the financial resources that can facilitate the improvement plan. Funds would be needed to purchase technological equipment for the CPOE. Also, developers of the system would require monetary compensation. Regarding implementing the simulation-based training program, leaders of several departments in the hospital would be necessary to facilitate the process. They would have to organize their departmental staff members on how they would participate in the activity. They would help develop a list of scenarios to include in the training. Resources at the hospital, such as medications, would be used to facilitate the process.


Overall, evidence-based strategies targeting factors causing medication errors can effectively minimize these errors. Factors that can cause the administration of the wrong dose of medication include interruptions, illegible handwriting, and lack of contact information to facilitate communication between healthcare professionals. Evidence-based strategies such as using CPOE and simulation-based training are essential components of an improvement plan to promote patient safety.


Bhutada, A. (2020). Incidence of medication error in critical care unit of tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 753–754.

Huckels-baumgart, S., & Manser, T. (2021). SeparateMedication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study. Journal of Patient Safety, 00(00), 1–8.

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett-Jones, T., Weidemann, G., Aguilar, V., & Everett, B. (2019). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7), 498–507.

Kellogg, K. M., Puthumana, J. S., Fong, A., Adams, K. T., & Ratwani, R. M. (2021). Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system. Journal of Patient Safety, 17(8), E1394–E1400.

Khalil, H., Kynoch, K., & Hines, S. (2020). Interventions to ensure medication safety in acute care: an umbrella review. International Journal of Evidence-Based Healthcare, 18(2), 188–211.

Moudgil, K., Premnath, B., Shaji, J. R., Sachin, I., & Piyari, S. (2021). A prospective study on medication errors in an intensive care unit. Turkish Journal of Pharmaceutical Sciences, 18(2), 228–232.

Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., Faudel, A., & Rioufol, C. (2019). Human-simulation-based learning to prevent medication error: A systematic review. Journal of Evaluation in Clinical Practice, 25(1), 11–20.

Schutijser, B. C. F. M., Klopotowska, J. E., Jongerden, I. P., Spreeuwenberg, P. M. M., De Bruijne, M. C., & Wagner, C. (2019). Interruptions during intravenous medication administration: A multicentre observational study. Journal of Advanced Nursing, 75(3), 555–562.


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You can use a supplied template for this assessment to conduct a root-cause analysis. The completed evaluation will be a scholarly paper focusing on a quality or safety issue about medication administration in a healthcare setting of your choice and a safety improvement plan.

Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Of course, root-cause analyses are conducted, and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach to identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans and disseminate vital information to staff nurses and other healthcare professionals to protect patients and improve outcomes.

Completing the Quality and Safety Improvement Plan Knowledge Base activity and reviewing the various assessment resources would be an excellent choice as you prepare for this assessment. This will help you build your knowledge of critical concepts and terms related to quality and safety improvement. The terms and ideas will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Demonstration of Proficiency
By completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event about medication administration. ;
Create a viable, evidence-based safety improvement plan for safe medication administration.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event about medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Communicate logically and professionally by writing with correct grammar and spelling using the current APA style.
Professional Context
Nursing practice is governed by health care policies and procedures and state and national regulations developed to prevent problems. Nurses must participate in gathering and analyzing data to determine the causes of patient safety issues, solve problems, and implement quality improvements.

For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

The specific safety concern identified in your previous assessment about medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
Instructions: This assessment aims to demonstrate your understanding of and ability to analyze the root cause of a specific safety concern in healthcare. You will create a plan to improve patient safety related to medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen healthcare setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, corresponding to the grading criteria in the scoring guide. Please study the scoring guide carefully to understand what is needed for a distinguished score.

Analyze the root cause of a patient safety issue or a specific sentinel event about medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issues or sentinel events about medication administration.
Create a feasible, evidence-based safety improvement plan for safe medication administration.
Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
Using the current APA style, communicate in clear, logical, and professional writing, with correct grammar and spelling.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like. However, remember that your Assessment 2 will focus on safe medication administration.

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