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

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

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

Course: NURS FPX 4020 Improving Quality of Care and Patient Safety

Assignment Title: Assessment 2: Root-Cause Analysis and Safety Improvement Plan


The Root-Cause Analysis and Safety Improvement Plan Assignment for NURS FPX 4020 aim to enhance students’ understanding of medication administration errors in healthcare settings, particularly focusing on the progressive care unit. The assignment focuses on the identification of root causes for wrong-time medication administration errors (WTMAEs) and proposes a comprehensive safety improvement plan based on evidence-based strategies.

Understanding Assignment Objectives:

To excel in this assignment, students need to demonstrate a comprehensive understanding of the intricacies involved in medication administration, particularly focusing on the timing aspect. They should showcase their ability to critically analyze incidents, identify root causes, and apply evidence-based strategies to formulate a feasible improvement plan. Additionally, students are encouraged to think critically about the practical implementation of their proposed strategies and the resources required for successful execution.

The Student’s Role:

As a student undertaking the NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan Assignment, your role is to act as a healthcare professional in a progressive care unit. You are tasked with meticulously examining incidents of wrong-time medication administration errors, reporting your observations, and proposing evidence-based strategies to address the root causes. Your responsibilities include developing a comprehensive improvement plan, outlining resource mobilization, and critically reflecting on the potential outcomes and challenges associated with your proposed interventions.

This assignment provides an opportunity for you to integrate theoretical knowledge with practical considerations, fostering a holistic understanding of patient safety in medication administration within healthcare contexts. Ensure that your analysis and improvement plan align with best practices in the field and are supported by the latest research literature.

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


The timely administration of medications is paramount for patient health and safety. Wrong-time medication administration errors (WTMAEs) pose a significant threat to patient well-being. This paper conducts a root-cause analysis of WTMAEs in the progressive care unit and proposes an evidence-based safety improvement plan. The analysis identifies root causes such as high workload and interruptions. The improvement plan focuses on optimizing the Electronic Medical Administration Record (EMAR), implementing an effective error reporting system, and addressing interruptions through process changes and a culture shift. The plan leverages existing organizational resources to facilitate successful implementation.

Analysis of the Root Cause

As a nurse in a progressive care unit, my focus is on preventing medication administration errors (MAEs). I carefully monitor and reflect on our working processes. Through this, I noticed challenges in giving drugs to patients at the right time. Although the reported incidents didn’t harm patients, the recurrence poses significant risks. Wrong-time medication administration errors (WTMAEs) involve giving a drug an hour earlier or later than prescribed, impacting patients by delaying treatment and potentially causing harm (Martin et al., 2020).

MAEs often result from failures in the six rights of drug administration: right medication, dose, time, patient, route, and documentation (Yousef et al., 2022). In the incidents investigated, the critical issue was difficulty in providing the correct timing of drug administration. Studies by Raja et al. (2019), Furnish et al. (2021), and Tsegaye et al. (2020) point out factors like personnel shortage, communication problems, lack of awareness, and interruptions as common causes of errors.

Examining the root causes in our progressive care unit, the challenges stem from the complexity of patients’ conditions and high workload, along with regular interruptions disrupting our planned schedule. While the severity of patients’ conditions is inherent, we can address workload and interruptions. It’s crucial to control these factors to enhance patient safety.

Evidence-Based Strategies to Improve Medication Administration Safety

To prevent wrong-time medication administration errors (WTMAEs), there are practical measures we can consider. Furnish et al. (2021) suggest optimizing electronic records, adding special marks to drugs that need precise timing. This way, healthcare workers can pay extra attention to medications requiring specific timings. Similarly, Westbrook et al. (2020) affirm that using electronic systems for medications helps reduce errors, especially in high-workload situations where process optimization becomes crucial.

Error reporting is another key aspect of preventing medication errors. In our progressive care unit, we usually create records or inform our managers about errors. However, Mutair et al. (2021) emphasize the need for a comprehensive error reporting system that encourages non-punitive reports, fosters a supportive environment, ensures responsiveness, and involves expert analysis. Such a system contributes significantly to enhancing safety in drug administration by optimizing workflows under high workloads.

Addressing interruptions is crucial to reducing medication errors. Huckels-Baumgart et al. (2021) and Kavanagh and Donnelly (2020) found that having a separate room for preparing drugs lowers the chances of interruptions and errors. This issue is also linked to communication. Insights from nurses, as highlighted by Laustsen and Brahe (2018), show that maintaining a working culture that prioritizes task focus, encourages prioritization, and supports specialist collaboration can effectively reduce interruptions. It’s about creating a professional environment where nurses can decline interruptions and provide feedback if needed.

Improvement Strategies to with Evidence-Based and Best-Practice Strategies Address Medication Administration Errors

This paper suggests a plan to improve the situation with wrong-time medication administration errors (WTMAEs) in the progressive care unit. The plan focuses on tackling the root causes, mainly the high workload and interruptions. The first step involves optimizing the EMAR system to highlight drugs with specific time requirements (Burnish et al., 2020). This is crucial because it helps healthcare workers pay extra attention to the timing of drug administration, especially in busy situations where it might be challenging to assess drugs accurately.

The next part of the plan emphasizes creating a structured process for reporting and analyzing medication administration errors (MAEs). The current reporting system may lack cohesion, leading to the possibility of missing essential information. Furthermore, seeking expert reviews of error reports in a non-punitive and supportive manner is essential for improving practices (Mutair et al., 2021). This step contributes to the overall goal of optimizing the workload and reducing the likelihood of errors.

To address interruptions, the subsequent steps of the plan propose changes in drug administration processes and the transformation of the working culture. Drug administration requires concentration from healthcare professionals, making it vital to minimize external factors’ influence. Measures such as organizing special rooms and quiet zones are suggested to create an environment that supports focus on administering prescribed medicines (Huckels-Baumgart et al., 2021).

Transforming the work culture is a more extensive effort aimed at changing employee behavior. The new culture aims to bolster nurses’ professional competencies in drug administration and enhance their ability to stay focused on tasks (Laustsen & Brahe, 2018). Since work culture significantly impacts the frequency of interruptions, the transformation goal is to normalize communication. This means employees should feel empowered to halt interruptions, refuse them, and express the need to focus on administration and other operational aspects. The desired outcome is to reduce interruptions and their impact on drug administration, ultimately decreasing the occurrence of WTMAEs.

Implementing this plan involves numerous steps and measures, requiring both technical organization and personnel training. The most extended period will be dedicated to changing the culture, as it involves shifting employee habits. The initial development and implementation phase is estimated to take one year, with room for refinements based on evaluating the effectiveness of specific actions in each aspect.

Utilizing Existing Organizational Resources for Improvement

To put the improvement plan into action, the hospital needs to make use of its existing resources. Optimizing the EMAR system involves getting help from information technology specialists, preferably those familiar with the current system. This may include reaching out to the system provider for support (Root-Cause Analysis and Safety Improvement Plan Research Paper). Additionally, utilizing the skills of existing staff and potentially bringing in coaches for training on necessary behaviors and error analysis is crucial. However, it’s important to recognize that changing workflows will take time for employees to adapt.

Creating quiet zones, a specific space designed for preparing medicines, is also part of the plan and requires resources. This involves organizing a comfortable space for healthcare workers. Allocating resources for these initiatives is essential to ensure the success of the improvement plan.

Addressing Medication Administration Errors: A Call to Action

After closely observing a progressive care unit, it became evident that Wrong-Time Medication Administration Errors (WTMAEs) pose a significant risk. When patients take their medications at the incorrect time, it not only diminishes the effectiveness of the treatment but also jeopardizes their well-being, placing an additional burden on the hospital. These errors stem from the complex conditions of patients and the demanding workload on the staff. Moreover, frequent interruptions further disrupt the workflow, contributing to the occurrence of WTMAEs.

To address these challenges, the paper proposes an improvement plan rooted in evidence-based strategies. This plan advocates for changes in the Electronic Medical Administration Record (EMAR) system, refining the error reporting process, establishing quiet zones, and transforming the work culture to minimize interruptions. These measures are aimed at optimizing work processes, ultimately reducing the occurrence of WTMAEs and enhancing patient safety.


In summary, examining the medication practices in the progressive care unit reveals a significant number of Wrong-Time Medication Administration Errors (WTMAEs). The potential outcomes of these errors, including reduced treatment effectiveness and increased patient harm, highlight the need to address this issue. The identified root causes, linked to complex patient conditions, high workload, and frequent interruptions, call for a comprehensive and evidence-based approach. The proposed improvement plan, covering improvements to the EMAR system, a streamlined error reporting process, creation of quiet zones, and a shift in the work culture, aims to mitigate these challenges. By optimizing work processes and minimizing interruptions, the plan seeks to reduce the occurrence of WTMAEs, contributing to a safer healthcare environment. However, it is crucial to recognize that implementing these changes requires collaborative efforts, involving technology specialists, staff training, and allocating resources for creating designated quiet zones. The projected timeline for this improvement plan is one year, with ongoing evaluations and refinements as necessary. In the pursuit of safer patient care, this paper emphasizes the need for a proactive and straightforward strategy. By addressing the root causes and implementing evidence-based interventions, healthcare professionals can work collaboratively towards a healthcare setting that prioritizes patient safety and minimizes the risk of medication administration errors.


Burnish, C., Wagner, S., Dangler, A., Schwarz, K., Trujillo, T., Stolpman, N., & May, S. (2021). Evaluation of medication administration timing—Are we meeting our goals? Journal of Pharmacy Practice, 34(5), 750–754.

Furnish, C., Wagner, S., Dangler, A., Schwarz, K., Trujillo, T., Stolpman, N., & May, S. (2021). Evaluation of medication administration timing—Are we meeting our goals? Journal of Pharmacy Practice, 34(5), 750–754.

Huckels-Baumgart, S., Baumgart, A., Buschmann, U., Schüpfer, G., & Manser, T. (2021). Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: A prospective observational study. Journal of Patient Safety, 17(3), 161-168.

Kavanagh, A., & Donnelly, J. (2020). A Lean approach to improve medication administration safety by reducing distractions and interruptions. Journal of Nursing Care Quality, 35(4), 58-62.

Laustsen, S., & Brahe, L. (2018). Coping with interruptions in clinical nursing—A qualitative study. Journal of Clinical Nursing, 27(7-8), 1497-1506.

Martin, K., Tilolele, M., Kennedy, S., Hanzooma, H., Luke, B., & Christabel, N. H. (2020). Wrong time medication administration errors: Frequency and their causes at Adult University Teaching Hospitals in Zambia. African Journal of Pharmacy and Pharmacology, 14(10), 362-369.

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines (Basel, Switzerland), 8(9), 1-12.

Raja, R., Badil, B., & Ali, S. (2019). Wrong time medication administration errors and its association with demographic variables among nurses in tertiary care hospitals, Karachi. Journal of the Dow University of Health Sciences (JDUHS), 13(1), 30-36.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13, 1621–1632.

Westbrook, J. I., Sunderland, N. S., Woods, A., Raban, M. Z., Gates, P., & Li, L. (2020). Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study. BMJ Health & Care Informatics, 27(3), 1-9.

Yousef, A. M., Abu-Farha, R. K., & Abu-Hammour, K. M. (2022). Detection of medication administration errors at a tertiary hospital using a direct observation approach. Journal of Taibah University Medical Sciences, 17(3), 433-440.

Detailed Assessment Instructions for the NURS FPX 4020 Root-Cause Analysis and Safety Improvement Plan Example

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue.

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. Often 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 for 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 as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts 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 successfully 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.
  • Create a feasible, evidence-based safety improvement plan.
  • Competency 2: Analyze factors that lead to patient safety risks.
  • Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
  • Identify existing organizational resources that could be leveraged to improve a plan.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing 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.
  • The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.
  • One of the case studies from the previous assessment.
  • A personal practice experience in which a sentinel event occurred.


The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the  Root-Cause Analysis and Improvement Plan Template [DOCX]  to help you to 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, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

  • Analyze the root cause of a patient safety issue or a specific sentinel event in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
  • Create a feasible, evidence-based safety improvement plan.
  • Identify organizational resources that could be leveraged to improve your plan.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

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