Root-Cause Analysis and Safety Improvement
NURS-FPX4020
Capella University
Root-Cause Analysis and Safety Improvement Plan
In the healthcare setting, the main goal in the organization is to provide patient safety. A
Root Cause Analysis (RCA) is utilized to identify and solve problems and prevent them from
reoccurring (Tsuchiya, 2020). Many times the information is for the RCA is obtained by
medical personnel and an incident report is put together for the purpose of determining what risk
factors actually contribute to the occurrence of the incident. This RCA will focus on medication
administration errors and the best way to avoid or drastically minimize them. These errors will
be analyzed, determine which evidence based strategies will help alleviate the problem and find
an improvement plan utilizing the existing organization resources.
Analysis of the Root Cause
Medication administration errors are the third leading cause of death in the US with more
than 250,000 cases (Miller, 2022). One of the root causes is interruption or distraction during the
medication administration preparation process (Mortaro et. al., 2019). This is a responsibility
, that falls solely on the nurse and if a medication error were to occur, it would come back on this
individual. Distraction cause the nurse to bypass some of the right to verify prior to
administering a medication and this could cause serious harm to the patient or even death. An
incident that occurred at a nearby medical organization involved a new graduate nurse and a nine
month old child. The child presented to the emergency facility for fever and vomiting. After
examination, it was determined that the child had strep throat. The new graduate nurse was
ordered to give Bicillin IM, however, the medication was given IV. This mix up in
administration location resulted in the child losing toes on one foot, a below the knee amputation
on the other extremity surgery on her private area due to necrotic tissue. This incident was said to
be caused by the new graduate nurse being stressed about being a new nurse.
NURS-FPX4020
Capella University
Root-Cause Analysis and Safety Improvement Plan
In the healthcare setting, the main goal in the organization is to provide patient safety. A
Root Cause Analysis (RCA) is utilized to identify and solve problems and prevent them from
reoccurring (Tsuchiya, 2020). Many times the information is for the RCA is obtained by
medical personnel and an incident report is put together for the purpose of determining what risk
factors actually contribute to the occurrence of the incident. This RCA will focus on medication
administration errors and the best way to avoid or drastically minimize them. These errors will
be analyzed, determine which evidence based strategies will help alleviate the problem and find
an improvement plan utilizing the existing organization resources.
Analysis of the Root Cause
Medication administration errors are the third leading cause of death in the US with more
than 250,000 cases (Miller, 2022). One of the root causes is interruption or distraction during the
medication administration preparation process (Mortaro et. al., 2019). This is a responsibility
, that falls solely on the nurse and if a medication error were to occur, it would come back on this
individual. Distraction cause the nurse to bypass some of the right to verify prior to
administering a medication and this could cause serious harm to the patient or even death. An
incident that occurred at a nearby medical organization involved a new graduate nurse and a nine
month old child. The child presented to the emergency facility for fever and vomiting. After
examination, it was determined that the child had strep throat. The new graduate nurse was
ordered to give Bicillin IM, however, the medication was given IV. This mix up in
administration location resulted in the child losing toes on one foot, a below the knee amputation
on the other extremity surgery on her private area due to necrotic tissue. This incident was said to
be caused by the new graduate nurse being stressed about being a new nurse.
