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Capella 4020 Assessment 2

Capella 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Student Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name


Root-Cause Analysis and Safety Improvement Plan

This document embarks on a meticulous exploration of a sentinel event that transpired in the cardiology ward of City Hospital, specifically concerning medication administration to Mrs. Smith. This pivotal event, where a medication misadministration occurred, offers a profound glimpse into healthcare professionals’ multifaceted challenges in their relentless pursuit of impeccable patient care. In the ensuing pages, we will undertake a systematic root-cause analysis (RCA) to unearth the core factors that facilitated this oversight.

Following the RCA, we will present a robust safety improvement plan anchored in evidence-based methodologies and best practices tailored to rectify and prevent such discrepancies in the future. This discourse aims to give readers an exhaustive comprehension of the incident, its causative elements, and the proposed remedial measures.

Analysis of the Root Cause

At City Hospital’s cardiology ward, an unsettling medication error brought to light significant systemic vulnerabilities. Mrs. Smith, a 68-year-old patient, was inadvertently given ‘metformin,’ a medication for diabetes, instead of her prescribed ‘metoprolol,’ a beta-blocker tailored for her heart condition. This error only surfaced the following morning when a more vigilant or perhaps familiar nurse spotted the discrepancy during her routine medication rounds.

Addressing the immediate implications, Mrs. Smith, being the primary subject of this mistake, experienced unnecessary distress. The strain of being diagnosed with hypertension and heart failure was intensified when she was erroneously given a medication unrelated to her medical profile. This incident points to a cascade of issues, ranging from individual oversight to broader systemic gaps.

Diving deeper into the sequence of events, Mrs. Smith’s medication regimen was clear and explicitly laid out. As a patient diagnosed with hypertension and heart failure, her medical profile necessitated the administration of ‘metoprolol.’ However, a couple of factors converged, leading to the oversight. First, the nurse’s misinterpretation of the prescription within the EHR system made her confuse ‘metoprolol’ with ‘metformin.’ The healthcare setting, particularly the bustling cardiology ward, presented multiple challenges.

Capella 4020 Assessment 2

The noise, potential distractions, or the stress of managing several patients simultaneously may have contributed to the lapse. Such environments demand robust systems to preempt potential errors. Mrs. Smith’s lack of a double-check mechanism for medication dispensation became a glaring omission. The pivotal role of such systems is underlined by healthcare governing bodies, such as The Joint Commission (Rodziewicz et al., 2023). Had such a protocol been followed diligently, the medication error concerning Mrs. Smith could have been averted. Delving into specific root causes:

  • Equipment or Resource Factors: Though designed to streamline and improve patient care, the EHR system had shortcomings. A more proactive system would have flagged the discrepancy between Mrs. Smith’s medical profile and the prescribed ‘metformin.’
  • Human Errors or Factors: The nurse, due to fatigue, multitasking, or oversight, failed to read and administer the medication correctly. More rigorous training or periodic refresher courses could act as preventive measures.
  • Communication Factors: The cardiologist verbally relayed the change in medication to the nurse. Reliance on verbal communication introduces potential gaps without written or electronic confirmation. Improved communication protocols, where critical information is both verbally discussed and electronically confirmed, can bridge such gaps.

Application of Evidence-Based Strategies

As exemplified in Mrs. Smith’s case, medication administration errors underline the urgency for evidence-based strategies in healthcare settings. Implementing these strategies to improve patient safety is crucial and grounded in rigorous research and studies. Many factors are pinpointed in literature as leading causes of medication errors.

The FDA has emphasized the challenges posed by phonetic and orthographic similarities between drug names, contributing to confusion (FDA, 2021). Furthermore, the pitfalls of verbal communication, especially in noisy healthcare environments, are highlighted by the ISMP (ISMP, 2019). Moreover, Jhala & Menon (2020)provided compelling evidence that interruptions during medication administration can escalate the risk of errors by 12.1%.

Evidence-Based Strategies and Their Application

  • Drug Name Clarification in EHR Systems: Supported by the World Health Organization, technology that flags similarly named drugs can significantly diminish medication errors (World Health Organization, 2019). In Mrs. Smith’s scenario, a system that differentiates ‘metoprolol’ from ‘metformin’ would have prompted verification, preventing misadministration.
  • Electronic Alerts in EHR Systems: The AHRQ (2019) advocates for enhancing EHRs to issue proactive alerts when there is a mismatch between diagnosed conditions and prescribed medications. Applying this to Mrs. Smith’s case, an alert would have been triggered due to the inconsistency between her cardiac condition and the prescribed diabetic drug.
  • Enhanced Training for Medication Administration: Regular, targeted training sessions for healthcare professionals are of paramount importance (Elkeshawi et al., 2022). In real-world scenarios like Mrs. Smith’s, a recently trained nurse would likely be more vigilant, cross-verifying the medication or actively seeking clarifications upon encountering any ambiguities.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The domain of medication administration, while crucial, is susceptible to errors, particularly in busy healthcare environments. Mrs. Smith’s incident underlines the profound repercussions of such oversights. However, by amalgamating insights from scholarly and professional resources, we can formulate a potent safety improvement plan to eliminate these discrepancies and ensure patient safety. Several proactive measures should be implemented to enhance patient safety during medication administration.

Every medication to be administered should mandatorily undergo a secondary verification process. This verification, preferably executed by a different healthcare professional, ensures an added layer of scrutiny. Such a systematic approach would substantially diminish the chances of oversight or misinterpretation. The Joint Commission’s endorsement of independent double-checks underscores the efficacy of this practice in averting medication errors (Rodziewicz et al., 2023).

Though comprehensive, the current Electronic Health Record (EHR) system necessitates specific enhancements. Integrating a refined alert mechanism that identifies medications with phonetically or orthographically similar names would preempt potential confusion. Moreover, a cross-referencing feature, which checks the prescribed medication against the patient’s recorded diagnoses, ensures congruence. The Agency for Healthcare Research and Quality (AHRQ, 2019) has highlighted the instrumental role of such advanced EHR systems in minimizing medication-related discrepancies.

Capella 4020 Assessment 2

Knowledge upgradation remains a cornerstone of error prevention. Instituting regular, structured training sessions for healthcare professionals is pivotal. These sessions, bolstered by real-world case studies and expert insights, would focus on potential pitfalls in medication administration and their prevention. Continuous education, especially targeting medications prone to misidentification, reinforces best practices and deters inadvertent mistakes (Elkeshawi et al., 2022).

Facilitating transparent communication channels among healthcare stakeholders, notably physicians, nurses, and pharmacists, is crucial. This collaborative approach ensures a unified, coherent understanding of medication protocols, promoting clarity and minimizing ambiguities. This proactive communication channel would act as a conduit for verification, clarification, and discussion related to medication protocols.

The primary objective is substantially reducing medication administration errors, if not complete eradication. We envisage a fortified patient safety culture and continuous professional growth by implementing the above strategies. The desired milestone is a marked decline in medication-related incidents in the forthcoming year.

We have mapped out a strategic timeline for implementing key initiatives to bolster medication administration safety. The Double-Check System will be introduced immediately in the forthcoming month. The EHR system’s enhancements will be phased over the next six months, allowing for regular checks and adjustments. Training initiatives targeting medication safety will commence in two months, with subsequent updates every quarter. A streamlined communication framework is also set for rollout in the upcoming quarter to facilitate clear communication across the care team.

Existing Organizational Resources

The healthcare organization has several existing resources that can be pivotal in driving the improvement plan forward. While functional, the current Electronic Health Record (EHR) system offers room for enhancement. We can leverage its capabilities to address medication name confusions and condition-medication mismatches by integrating advanced alert systems and cross-referencing algorithms. Additionally, our in-house training departments are a valuable asset. They have the expertise and infrastructure to orchestrate regular, targeted workshops to reinforce medication safety practices. These sessions, tailored to address the specific challenges identified, can significantly reduce human errors in medication administration.

Feedback mechanisms such as reporting systems and suggestion portals can be channeled to gather insights directly from the frontline staff. Their on-ground experiences can provide invaluable insights into the nuances of day-to-day challenges, aiding in fine-tuning our safety strategies. Moreover, our interdisciplinary committees, which already facilitate collaborative discussions across departments, can be instrumental in this endeavor. A collective of physicians, nurses, pharmacists, and IT professionals can collaboratively address the multifaceted challenge of medication safety. By prioritizing these resources based on their potential impact; we can devise a holistic approach to mitigating medication administration errors, ensuring patient safety, and fostering trust.


In conclusion, the root-cause analysis has illuminated vital areas of improvement in medication administration. Evidence-based strategies provide a clear path toward enhancing patient safety. Continuous training and technological advancements can drastically reduce medication errors. Our collective efforts in implementing these measures will undoubtedly foster a safer healthcare environment.


Agency for Healthcare Research and Quality. (2019). Electronic health records | PSNet. 

De Baetselier, E., Dilles, T., Feyen, H., Haegdorens, F., Mortelmans, L., & Van Rompaey, B. (2021). Nurses’ responsibilities and tasks in pharmaceutical care: A scoping review. Nursing Open, 9(6). 

Elkeshawi, R., Maddox, K., Xenophontos, A., & Hampson, K. (2022). Safety considerations for the inpatient medication-use process in pediatric and neonatal patients. Patient Safety, 30–35. 

Capella 4020 Assessment 2

ISMP. (2019, May 19). Institute for Safe Medication Practices. 

Jhala, M., & Menon, R. (2020). Examining the impact of an asynchronous communication platform versus existing communication methods: an observational study. BMJ Innovations, 7(1), 68–74. 

Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2023, May 2). Medical error reduction and prevention. National Library of Medicine. 

U.S. Food and Drug Administration. (2021). U S Food and Drug Administration Home Page. 

World Health Organization. (2019). Medication Without Harm. 

Capella 4020 Assessment 2