Root-Cause Analysis and Safety Improvement Plan

Topic: Nursing
Words: 1199 Pages: 4


Root-cause analysis refers to a methodical strategy that aims at finding the causes of different events to suggest relevant preventive measures. A root-cause analysis of nurses’ roles in medication administration safety was conducted to investigate the roles of nurses in medical administration safety and provide relevant recommendations that can be adopted to alleviate the challenges that nurses face in this field. The paper will therefore provide a detailed description of the roles of nurses in medical administration safety and propose a safety improvement plan through the utilization of existing organization resources.

Analysis of the Root Cause

Nurses play a vital role in examining the associated risks and realizing an effective administration plan. Considering the adverse implications paused by poor drug administration safety, a detailed root-cause analysis was conducted to establish how aspects such as poor communication and delays in seeking medical intervention can contribute to patient safety risks. Therefore, the objective of this analysis was to establish the roles of nurses in medication administration safety in a healthcare facility (Rohde & Domn, 2018). The case analysis revealed that nurses play a critical role in medication administration plans to realize effective healthcare provision. The analysis also indicated that the majority of the risks related to drug administration are brought about by the patients and can be avoided by a collective working between the patients and the nurses.

In addition, the analysis revealed that the safety risks exposed to the patients often involve the manifestation of actions such as poor concentration on body fluids, incorrect provision of dosage to patients and wearing of anaesthetic prescription during surgical operations (Hammoudi, Ismaile, & Abu Yahya, 2018). Poor medical administration may also be associated with the patients in the event of a need for quick response and cases of patient emergency (Rohde & Domn, 2018). Similarly, instances of failed communication called misdiagnosis between the patients and the nurses may also lead to wrong medicine prescription for the patients due to withholding of essential information by the patient and patient’s lack of confidence that is vital for efficacy in diagnosis schedules. Delay in acquiring medical intervention for the patient also plays a significant role in patient-specific risks that have to be solved by the nurses. The delay in medical intervention schedules contributes to poor medical administration due to a lack of relevant information concerning the patient’s condition and quality of life.

Application of Evidence-Based Strategies

Considering that nurses play a vital role in medication administration safety, various strategies can be adopted to address the safety issue. According to the literature by Heczkova and Bulave (2018), some of the key causes of poor medical administration in the nursing field entail provision of incorrect dosage of drugs to the patient, poor concentration by the nurses on body fluids, and wearing off an anesthetic prescription during surgical operations. In addition, the author revealed that poor communication between the patient and the nurses plays a vital role in the wrong administration of the drugs, thus affecting the efficiency of the process (Johnson et al., 2017). These strategies that have been recommended by the authors in their article can be addressed fully by ensuring proper and immediate decisions concerning the disease between the patient and the nurse (Heczkova & Bulave, 2018). In addition, there is a need to establish good rapport between the patient and the nurse to eliminate the possible occurrence of failed communication that may result in poor medical administration by the nurses. Rohde and Domn (2018) in their article have also suggested that there is a need to promote strategies that would eliminate delays in medication administration, such as efficient patient probing on the severity of the patient situation and the quality of life.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan to reduce the possible occurrence of poor medication administration by the nurses involves a two-prolonged approach. These approaches entail the introduction of benchmarking programs in the healthcare setting and increasing facilities and systems adopted in the healthcare institution. The first improvement plan emphasizes the need to increase the efficiency in medication administration by the nurses by boosting the nurse’s confidence while handling drugs. According to Jonson et al. (2017), the adoption of benchmarking practitioner programs will enable nurses to largely focus on the demographics of the patients and eliminate the risk factors associated with drug administration. With such a plan, nurses’ knowledge concerning medicine administration will greatly improve, thus eliminating the possible occurrence of faults during the administration process. Therefore, in a bid to reinforce drug administration, it is significant to adopt a practitioner exchange program on medicine administration.

Secondly, there is a need to increase systems and facilities in the healthcare systems. Such facilities and systems that need to be boosted include developing a well-funded policy for the patients, increasing bed capacities and space, increasing the number of qualified nurse practitioners. The study done by Rohde and Domn (2018) revealed that the increase in the nursing systems and facilities will help to reduce pressure and workload, thus reducing the risks of poor drug administration. In addition, a subsequent increase in the number of highly trained personnel will help to reduce the risks of patients being acquainted with poor medicine administration.

The proposed improvement plan aims at ensuring that nurses are equipped with the necessary resources and facilities that will enable them to address challenges related to poor medication administration. The critical outcomes expected after the adoption of the above improvement plan include reduced workload for the nurses, improvement of the quality of life, and a focus on patient well-being that would help to alleviate the associated patient risks (Heczkova & Bulave, 2018). The above improvement plan should be developed within three weeks and later be immediately implemented to reduce the high cases of poor medicine administration that are evident in many healthcare facilities. Some of the evidence-based strategies that should be adopted include medication management, the formation of quality, and the patient safety team that will greatly help boost nurses’ role in medication administration.

Existing Organizational Resources

The existing organizational personnel that would help improve the implementation or outcomes of the plan are the stakeholders in the healthcare sector. Such stakeholders include government organizations dealing with pharmaceutical products, doctors, patients, facility employees, and insurance (Hammoudi, Ismaile, & Abu Yahya, 2018). The major resources that will be required to realize the success of the above improvement plan include pharmaceutical products, qualified practitioners to offer benchmarking services, bed spaces and capacity, and a well-funded insurance policy. The major existing resources that may be leveraged to enhance the improvement plan include qualified practitioners and bed capacities.


Nurses play a vital role in medication administration and therefore there is a need for them to be made aware of such roles to convince their stakeholders. A root-cause analysis of the nurse’s roles in medication administration was conducted at an inpatient healthcare unit and revealed that nurses should convince their stakeholders of their roles to receive their support and resources. The paper also highlights various evidence-based strategies, such as medication management, that can help to alleviate poor nursing roles in medication administration. The plan involved benchmarking and increasing facilities and systems used in the healthcare sector.


Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences, 32(3), 1038-1046. Web.

Heczková, J., & Bulava, A. (2018). Nurses’ knowledge of the medication management at intensive care units. Pielegniarstwo XXI Wieku/Nursing in the 21st Century, 17(1), 18-23. Web.

Johnson, C. O., Pettersson, J., Rybing, J., Nilsson, H., & Prytz, E. (2017). Short simulation exercises to improve emergency department nurses’ self-efficacy for initial disaster management: Controlled before and after study. Nurse Education Today, 55, 20-25. Web.

Rohde, E., & Domm, E. (2018). Nurses’ clinical reasoning practices that support safe medication administration: An integrative review of the literature. Journal of Clinical Nursing, 27(3-4), 402-411. Web.

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