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

Root cause analysis.

Root-cause analysis is used to point out the causes of adverse occurrences or explore options to prevent them from happening again. The root-cause analysis focused on medication errors and was performed in a nursing home facility following death of a resident patient due to wrongful discontinuation of the medication. This paper explores medication errors and looks at evidence-based and best practices methods to reduce medication errors. Further, the paper suggests a safety improvement plan with a basis on the use of available resources to address the problem.

Analysis of the Problem

The root-cause, in this case, was instigated by the untimely death of an 80-year-old at a nursing home. Angie broke her right; she was taken to the hospital and, after an ORIF was done, transferred back to the nursing home. Angie had been given new medications and ordered to continue taken her previous prescriptions as she had a known history of congestive failure that had lately presented with frequent exacerbations. Having two medication administration forms in her file contributed to the error. The nurse administering the drug was also distracted by a phone call, signaled a colleague who unintentionally interpreted the indication of Lasix on the new MAR as duplication, and yellowed it out. The medication continued without administration of Lasix.

Consequently, presumed to have been discontinued, Lasix was removed from the cart and sent back to the pharmacy. Days later, Angie’s condition worsened, and resuscitation efforts proved futile. She went into a cardiac arrest and passed on. The sudden death of a patient who had recently responded to treatment affected the nurse in charge, who sought to probe the matter. The event also affected all the nurses at the home, the administration, and the physician who attended to Angie at the hospital.

The medication process has standard laid out procedures. In Angie’s case, the attending nurse should have pursued the yellowing of Lasix to ascertain the reason. The attending should not have removed the old Medication Administration Record from the patient’s file. Maintaining the said record in the patient’s file would have allowed drug reconfirmation when during the next round of administration. Given the history of Congestive Cardiac failure, the discontinuation of Lasix should have raised eyebrows, prompting further investigation into the reason behind such a decision. Noteworthy is that the environmental factors that contributed to the sad occurrence were controllable. The distraction brought about by the phone call was too huge and the epicenter of the mistake. All stakeholders should have harmonized administration of medication. The communication was appropriate all through save for handing the file midway when picking the call. Therefore, the root causes for the grievous error were modifiable environmental distractions, failure to adhere to standard administration protocols, and modifiable environmental factors.

Application of Evidence-Based Strategies

All nurses are vulnerable to committing medication errors. Workplace interruptions tend to increase the risk for medication errors, with Johnson et al. (2017) reporting that up to 99% of medication preparation or administration are interrupted. In this case, the interruption was the phone call, which caused the attending nurse to lose focus on patient needs and medications. A chaotic work environment can be detrimental to the results of nursing care. According to Johnson et al. (2017), the cost of medication errors remains high, and include lengthened hospital stay, lifetime physical injuries, increased cost of care, and in some cases, death of the patient. For this reason, there is need for healthcare institutions to effectively leverage existing human resources to ensure full employer participation in improvement activities, staff training and promotion of smooth communication between the different stakeholders. Such initiatives can make it easier for facilities to handle challenges and barriers in patient care. Further, administrators should highlight the importance of complete and comprehensive patient documentation to minimize errors of omission.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan for sustained patient within the facility will focus on three pertinent facets, namely improved communication between nurses and other stakeholders, enhanced collaboration, and elimination of detractors from the work environment, such as cell phones. The first step of this improvement plan entails improving communication between stakeholders to enhance awareness during the provision of care. Collaborative working ensures that nurses and physicians can verify patient information prior to making any changes pertaining to patient care. Further, the plan suggests team empowerment, especially with respect to policy execution, for better patient management (Zamboni, et al., 2020). Environmental adjustment by creating a telephone station to leave one’s contacts during the administration of medication is equally essential. Nurses should be advised not to use individual cell phones during shifts to minimize cases of distractions. With effective implementation, this plan can help improve the quality of services offered, in addition to minimizing the chances of human errors within the facility. The plan is time-bound, and analysis of progress should commence in two months to review its success or the need for adjustments.

Existing organization resources

It is paramount to identify and apply the available resources appropriately. The facility has enough resources that when employed efficiently, can result in a safe nursing home environment. Foremost, the facility has enough, well-trained nurses to handle the residents of the home. By efficiently applying their skills, knowledge and workplace exposure, the nurses are in a better position to provide safe care (Franks, 2020). Secondly, the facility has schedules for physician visits every week to ensure that patients receive the intended medical care. Finally, the facility’s human resource management team must ensure that nurses handle patients with minimum interruptions by creating well-defined schedules. Additionally, the management should make it a routine for the head nurse to check and approve all transfers and medication changes for patients within two hours of such change.


Arguably, medication errors are the leading cause of injury, death and increased healthcare costs within nursing homes. The root cause analysis of the causative factors explored in this paper reveal the causes and potential solutions to the issue of medication errors in nursing homes. As observed in the case discussed, nurse distraction occasioned by cell phone use during work hours resulted in the death of a patient, an occurrence that should not happen. This paper has reviewed in-depth evidence-based strategies needed to effectively address the problem, particularly by focusing on human and environment factors that tend to jeopardize service delivery.


  • Franks, A. (2020). Use of Simulations to Improve Clinical Judgment in New Graduate Nurses. Walden University.
  • Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett-Jones, T., Weidemann, G., Aguilar, V., & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7), 498-507. doi:10.1111/jonm.12486
  • Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and Prevention. In StatPearls. StatPearls Publishing.
  • Zamboni, K., Baker, U., Tyagi, M., Schellenberg, J., Hill, Z., & Hanson, C. (2020). How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implementation Science: IS15(1), 27.