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

Capella 4020 Assessment 2

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

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Capella University

NURS FPX 4020 Assessment 2

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Root-Cause Analysis and Safety Improvement Plan

A safety improvement plan invoked the creation and evolution of an entire system in order to create emphasis on predicting the outcomes of desired practices and create workflows that function effectively best in all circumstances both for healthcare organizations and patients. The root-cause analysis, on the other hand, inspects the situation at hand distinctively and based on case studies and provided evidence lays down on the pre-supposition and presumption of solutions. Kwok et al. (2020) put forward that the way root-cause analysis could be distinctively made successful is to align its components and causes. That way they can be addressed easily. It is also claimed that human mistakes and issues in medicine affect healthcare facilities. Similarly, it is also an important concern in the service provision and performance of the entire department. These medicinal and performance-based concerns lead to a bad reception by the patient from an institutional point of view (Karande et al., 2021). In the end, it befalls entire institutions and management to ensure these errors are omitted and proper protocol is followed. In this intent, root-cause analysis is considered a revolutionary and progressive step in identifying mentioned problems and putting forward a way in which these concerns could be sorted out. Hibbert et al. (2018) suggested that compartmentalizing, time management, and feasibility are important elements contributing to the implementation of effective root-cause analysis. Respective research focuses on the root-cause analysis of medication errors by systemic and management concerns in the healthcare sector administered through evidence-based material. Therefore, the methods and structures improving the concerns of patients will be identified through evidence-based approaches. The involvement of the entire institution in the process is also taken into consideration.

Root-Cause of a Patient Safety Issue

Shin et al. (2021) organized patient safety incidents and associated factors in Korean hospitals. For this research, patient records of 2940 patients from the year 2017 were analyzed. Consequently, the data of 5889 patients from 2018, and 7389 from 2019 was considered for this research. The patient’s health deterioration in many cases resulted in death. In most cases, it was due to medication errors made due to patient healthcare records. According to data collected by the researchers, only sometimes patient health issues got worse due to medical complications, patient’s age, and immunity. These medication errors are solely based on inaccuracies in data collection or an error caused in patients’ health documentation. These medication errors occurred in medication, surgery, anesthesia, examination, infection, and contamination. To analyze the data Jonckheere-Terpstra (TJ) test was performed in order to analyze the types and trends of these issues caused and traced by the year (Shin et al., 2021). Regression Model 1 was utilized to understand and analyze the medication error. It was observed that over the years 49.8 percent of males and 50.2 percent of females encountered these errors. In a graph format, it was evaluated that 56.4 percent of these incidents occurred during the evening time and 59.0 percent were caused by the hands of the healthcare provider. Shin et al. (2021) declared this pattern as an indicator of extra workflow and external influence on healthcare providers to cause these issues. Even though an account of massive negligence and lack of organization was also documented but the graph’s logical structures suggest external influence more than then a choice.

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

Evidence-Based Safety Issue

Error caused in the medication process is always an uncertain occurrence in methodological, structural, and choice-based mistakes made by the entire healthcare institution as a collective. These mistakes indicate errors in administration, data collection, and distribution and a repeated set of choices exhibited by the staff and administration of the respective healthcare organization (Rodziewicz et al., 2021). World Health Organization (WHO) declared that less than ten percent of medication errors are directly deducted from management in general (Aldossary et al., 2021). The Institute of Medicine (IOM) suggested that more the 50,000 patients in healthcare centers experienced problems concerning medicine provision or issuance. More than seven percent of admitted children experience severe repercussions due to medicine because their body is not immune to any external agent which does not support their treatment (Aldossary et al., 2021). 

Capella 4020 Assessment 2

Singh. G et al. (2022) reported that a 24-question analysis supporting the framework suggested by the Joint Commission was put forward which considered various factors contributing to the occurrence of medication errors. NURS FPX 4020 Assessment 2: Root-Cause Analysis and Safety Improvement Plan. These contributing factors included outward stimuli, management concerns, and issues related to the healthcare nurses to be specific. Other than that, errors in equipment-related concerns, situational effects, environmental problems, and problems related to the fair and proper education of the healthcare staff are also included. Furthermore, contingency plans, communication, and concerns about expected performance by the healthcare staff also caused it (Singh et al., 2022). The researcher suggested that a flexible work environment supported by suitable work hours which can create effective communication among the staff and aids them in fulfilling their work-centric expectations can help reduce the number of medication errors occurring (Singh et al., 2022).

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Evidence-Based Safety Improvement Plan

The suggested elements of an evidence-based safety improvement plan include monitoring data collection of the patient, digitizing the treatment process, and abiding by proper structures.  Wacker (2020) put forward effective solutions to help reduce and eliminate these concerns and propose a safety improvement plan to overcome the major concerns associated with medication. Although various steps are proposed and enlisted in this respect due to functional contingency room for improvement still exists. Wacker (2020) put forward rate-based learning for the nurses, an emphasis on learning outcomes within healthcare sectors, the approach of the patient towards their treatment plan and its results, and detailed instruction manuals for the health staff on patient care methods and its details are some steps that can help make this process efficient. Capella 4020 Assessment 2. Methodological structures, concerns in system execution, and inability to utilize proper structures result in patient death or for instance caused psychological and physiological inabilities for life (Preckel et al., 2020). Schmitz and Popovich (2018) dictated that these safety plans could well be executed by monitoring the data collection of patient health and its organization in a well-organized and up-to-date manner. Odell et al. (2019) propagated the use of up-to-date research including audio and documented interviews conducted with patients could assist in improving this process. Bowdle et al. (2018) identified that the effective use of barcodes can improve the efficiency of this process collectively by up to 50 percent.

Identify Organizational Resources

The suggested resource to solve medication errors in the healthcare sector is the development of interdisciplinary teams. Other resources include improvement in communication, installation of barcodes, and data digitization. These resources are proposed to improve the efficiency of this concern through the maintenance of proper interdisciplinary teams. These teams would not only help maintain the work environment but also ensure the efficiency of the workflow individually at all levels (Rayan et al., 2019). In this respect, the installation of barcodes and an organized set of instruction manuals could help simplify the concern. Capella 4020 Assessment 2. Other than that, reviewing the accuracy of drugs based on their prescription charts also assists in the matter of safe medication administration (Seger & Cannesson, 2020). It was also observed that drug allocation and its supply to the patient faced severe communication lapses which lead to the provision of the wrong drug to mal-adjusting the quantity of the said dose provided. Other than communication, the implication of extra workload on the nurses assisted by inconvenient work hours also made this process ineffective and against the favor of patients (Bivens et al., 2022). It was registered that approximately two billion dollars were wasted on wrongly used medication in five years till the year 2018. WHO has taken direct action in this matter by making this process more organized. The creation of a digitized filing system is an extension of this detailing. This digitization has well-formulated stages as

  1. Well-organized background data about the patient.
  2. Proposition and creation of materials to help maintain updates about patient health.
  3. Reviewing the updates regarding the updates on the patient protocol.
  4. Employing certain tests and evaluation techniques to help get detailed data about patient recovery.

These tests and evaluations suggested the healthcare sector’s job satisfaction and overall efficiency were well above 50 percent on the charts. This also indicated an intentional effort employed by nurses to help remove such concerns (Benton et al., 2019). In healthcare institutes, situation, background assessment, and recommendation (SBAR) were employed directly, and the result satisfaction reached up to nominal. These results suggest a probability of effective results deduced in the case of an improved work environment (Benton et al., 2019).

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


In healthcare institutes, prevention of medical errors and improvement of patient safety is considered important to maintain the environment of the healthcare sector and ensure overall productivity and patient safety. In this discussion, the primary concern is to identify the root-cause of the said medical error. It was determined that all the medicine-related concerns were exhibited by the unavoidable circumstances of the healthcare sector but were mainly caused by the staff. Medication-related errors can traverse as severely and could result in the potential loss of a patient’s life (Rayan et al., 2019). For this, the entire staff along with stakeholders and patients ought to collaborate together to delimit medication-related concerns. For this careful evaluation of the barcode and incorporation of SBAR techniques are important to deduce results.


Aldossary, D et al.  (2021). Assessment of medication errors among anesthesia clinicians in Saudi Arabia: A cross-sectional survey study. Global Journal on Quality and Safety in Healthcare.

Benton, S. et al. (2019). Usability assessment of an electronic handoff tool to facilitate and improve postoperative communication between anesthesia and intensive care unit staff. CIN: Computers, Informatics, Nursing, Publish Ahead of Print.

Bivens, C. L., Cresap, M., Halcomb, S., & Taylor, M. (2022). Anesthesia-to-post anesthesia care unit handoff standardization. Graduate Publications and other Selected Works – Doctor of Nursing Practice (DNP).

Bonds, R. L. (2018). SBAR tool implementation to advance communication, teamwork, and the perception of patient safety culture. Creative Nursing, 24(2), 116–123.

Bowdle, T. et al. (2018). Facilitated self-reported anesthetic medication errors before and after the implementation of a safety bundle and barcode-based safety system. British Journal of Anaesthesia, 121(6), 1338–1345.

Christensen, R. et al. (2019). Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative. Pediatric Anesthesia, 29(3), 265–270.

Capella 4020 Assessment 2

Hibbert, P. et al. (2018). Are root-cause analyses recommendations effective and sustainable? An observational study. International Journal for Quality in Health Care, 30(2), 124–131.

Karande, S. et al.  (2021). Minimizing medical errors to improve patient safety: An essential mission ahead. Journal of Postgraduate Medicine, 67(1), 1.

Kwok, Y. et al.  (2020). Our first review: An evaluation of effectiveness of root-cause analysis recommendations in Hong Kong public hospitals. BMC Health Services Research, 20(1).

Odell, D. et al. (2019). Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. Journal of the American College of Surgeons, 229(2), 175–183.

Preckel, B et al. (2020). Ten years of the Helsinki Declaration on patient safety in anaesthesiology. European Journal of Anaesthesiology, 37(7), 521–610.

Shin, et al. Trend analysis of patient safety incidents and their associated factors in Korea using National Patient Safety Report Data (2017~2019). International Journal of Environmental Research and Public Health, vol 18, no. 16, 2021, p. 8482. MDPI AG,

Singh, Gunjan. (2022).  Root-cause analysis and medical error prevention. National Library of Medical Sciences.

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