Root-Cause Analysis and Improvement Plan

Instruction Details

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 of medication administration safety 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 [DOCX] Download Root-Cause Analysis and Improvement Plan [DOCX]template 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 specific patient safety issue in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue.
  • Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
  • 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.

Sample Answer

Root Cause Analysis and Improvement Plan for Medication Administration Safety Concern in a Healthcare Setting


In a healthcare setting, there exists a concerning issue related to medication administration safety, warranting an in-depth analysis and a structured improvement plan. For the purpose of this exercise, let’s consider a scenario where frequent medication errors have been identified during the administration process, leading to patient safety concerns and potential adverse outcomes. This issue has prompted the need for a comprehensive root cause analysis (RCA) to identify underlying factors and the formulation of an evidence-based improvement plan to enhance medication safety protocols.

Root Cause Analysis

The RCA process will commence by utilizing established methodologies such as the ‘5 Whys’ technique and Fishbone diagrams to delve into the factors contributing to medication administration errors. Initial findings have revealed several potential root causes:

  1. Lack of Standardized Procedures: Inconsistent medication administration protocols and insufficient standardization across shifts could lead to confusion and errors in drug dosages or administration timing.
  2. Staff Training and Competency: Inadequate training, staff turnover, or inadequate ongoing education about medication administration techniques might contribute to errors.
  3. Communication and Information Transfer: Ineffective communication among healthcare professionals during patient handoffs might result in crucial information being missed or misinterpreted, impacting medication administration accuracy.
  4. Workload and Stress: High workloads, stress, and distractions in clinical settings could lead to oversight or errors during medication administration processes.

Improvement Plan

To address these identified root causes and enhance medication administration safety, a structured plan will be implemented:

  1. Standardized Medication Administration Protocols: Develop and implement standardized procedures for medication administration, emphasizing clear guidelines on dosage calculations, administration timings, and documentation. This plan will be integrated into the organization’s policy and communicated effectively to all staff members.
  2. Ongoing Staff Training and Competency Evaluation: Establish a continuous education program to ensure that all healthcare professionals involved in medication administration are adequately trained, updated on best practices, and regularly assessed for competency.
  3. Enhanced Communication and Information Transfer: Implement standardized handoff protocols to ensure crucial medication-related information is effectively communicated during patient transfers between shifts or departments. This may involve utilizing standardized tools or digital systems to facilitate accurate information transfer.
  4. Addressing Workload and Stress Factors: Conduct a review of staffing levels and workload distribution, aiming to mitigate stress and workload concerns among healthcare professionals. Implementation of strategies to manage stress and improve focus during critical tasks such as medication administration should be a priority.

Organizational Resources

Leveraging existing resources within the healthcare setting such as dedicated training departments, collaboration with experienced nursing educators, and the utilization of electronic health record systems could substantially aid the successful implementation of the improvement plan.

In conclusion, the proposed plan aims to mitigate medication administration errors by addressing their root causes through evidence-based strategies, thereby significantly improving patient safety within the healthcare setting.

This plan outlines a proactive approach, leveraging both internal resources and best practices, aiming for a safer and more reliable medication administration process within the hypothetical healthcare organization.

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