Root-Cause Analysis Comprehensive Nursing Paper Sample

Root cause analysis is a tool organizations, and institutions use to assess the operationality of various processes and functions. The same approach is used to investigate adverse events in health care and identify and address factors contributing to patient outcomes. Quality improvement is a critical aspect of the contemporary healthcare continuum, which seeks to deliver patient-centred care, improve access and enhance outcomes. Therefore, investigating how and why a patient incident has occurred is a foundational element for change and the development of recommendations. While medical administration is essential across health settings, this paper highlights a patient safety issue, root cause analysis, improvement plan with evidence-based and best-practice strategies, and existing organizational resources.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

(Root-Cause Analysis Comprehensive Nursing Paper Sample)
(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Root Cause Analysis

Over the past six months, Clarion Court Skilled Nursing Facility has recorded alarming figures of medication errors. This has concerned the facility’s management and the nursing staff as well as patients. The institution has a dedicated workforce comprised of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants (Cutler et al., 2018). Most recently, an incident occurred where a patient nearly experienced an overdose, and due to the increasing incidents of medication errors, Clarion Court Skilled Nursing Facility completed a root cause analysis to identify reasons for cause, strategies to mitigate them, and improvement plans for patient safety.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Analysis of the Root Cause

The Clarion Court Skilled Nursing Facility has a well-established workforce whose precise roles and responsibilities should be accomplished accordingly. Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants have different roles but are conjoined to pass medications to patients. Medication errors form a large percentage of all hospital cases, and in the last six months, at Clarion Court Skilled Nursing Facility, the cases have risen to 7%. A root cause analysis was necessary due to the many incidents, but the most recent one where a patient has received the wrong instructions for the medication administered.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

The patient was a regular and was on prescription medication. The medication incident occurred after the patient received a much stronger dosage than was actually prescribed on that day. The nurse on duty was not settled at work yet because she had just arrived for her morning shift. Although the patient was on a prescription, what changed was the strength of the medication, and she failed to take note of the change. Due to interruptions and miscommunication, the usual three pills were administered instead of the new dose of one pill, making the patient lethargic and unattended. Although the patient did not suffer any serious harm, a critical situation was in the offing, hence the need for a thorough root cause analysis.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Most, if not all, health settings strive to attain acceptable health standards free of medication errors and related deficiencies. Therefore, RNs, LPNs, and CNAs should adhere to the five rights of medication: right route, right patient, right time, right dose, and the right medication (Ghorbanzadeh et al., 2019). In Clarion Court Skilled Nursing Facility’s case, the RN administering dose to a patient failed to check drug labels against electronic medical records contravening the right dose and medication. Her actions resulted in an oversight that may result in serious patient harm if unchecked in future scenarios. Such errors are often attributed to technological hitches, but this was one. Sometimes nurses want to complete a task quickly and proceed to another activity disregarding policies and procedures. The RN in charge of the round should have been keen on the medication dosage. Similarly, a flag indicating a change in the medication should have been highlighted to all staff, including RNs, LPNs, and CNAs attending to the patient.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Lack of respect among personnel could have resulted in the medication error. Since CNAs work under the supervision of LPNs and RNs, their roles are mainly to assist and check on patients meaning. Therefore, some of their recommendations and observations can be ignored, leading to unpleasant outcomes. The RN was notified of the patient’s condition but seemingly was distracted and could not act on the CNA’s report observations of unusual behavior and lethargy. Health settings should establish better communication channels and collaboration between RNs, LPNs, and CNAs to improve patient safety outcomes. In addition, since CNAs interact with patients often, they observe the patients, their behavior patterns, and any other unusual activity; hence their input becomes vital. Health care settings should discourage staff from skipping essential procedures because of distractions and limited time to absolve themselves from unethical conduct and medication errors.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Improvement Plan with Evidence-Based and Best-Practice Strategies

Medical and safety issues create an unhealthy environment for health care management, staff, and residents. The last six months have been a nightmare for Clarion Court Skilled Nursing Facility, given that it has had to undergo scrutiny due to the high medication errors. RNs and LPNs strive to perform optimally in their capacities and save time resulting in unnecessary pressure (Harrington et al., 2016). Activity-filled environments cause many distractions for nursing staff and, in the process, may not follow policies and procedures, negatively impacting patient care and outcomes (Walpola et al., 2017). The level of nurse staffing in a health facility is an excellent determinant of outcomes; therefore, there is a need for institutions to ascertain if increasing or increasing staff can lead to better outcomes.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

The rights of medication administration have significant impacts on patient safety and outcomes. Bypassing a right of medication indicates an intention to skip policies and procedures, presenting unpleasant outcomes on patient health and the medical field. Although medication administration processes may be complex, RNs, LPNs, and CNAs should adhere to procedures not unless stated otherwise by governing institutions.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Some procedural errors can be mitigated by utilizing health resources effectively and being cautious. The HALT (hunger, angry, lonely, tired) model has proven effective in reducing human errors in the recent past. It employs an educative approach for staff through supportive frameworks that foster healthy relationships, guide emotional affliction on patient safety, and increase self and group awareness (“HALT: The dangers of hunger, anger, loneliness, and tiredness | Rehab,” 2021). Another approach that perhaps is the most advocated is fostering interprofessional collaboration and communication. Effective communication in the workplace means sharing ideas and educating others through open conversations. On the other hand, collaboration is based on learning essential skills and cultures, including accountability, autonomy, responsibility, respect, cooperation, and coordination. (Root-Cause Analysis Comprehensive Nursing Paper Sample)

(Root-Cause Analysis Comprehensive Nursing Paper Sample)

Existing Organizational Resources

A mission and vision guide every organization. Available resources at Clarion Court Skilled Nursing Facility foster collaborative environments that focus on in-service education and quality improvement programs. Due to a lack of synchrony between nursing staff, leadership becomes an essential component that health care management systems should address urgently. Some of the available resources for in-service education would include but are not limited to conference halls equipped with overhead projectors. Banners and other advertisement products will be placed around the facility, while management systems will recruit additional staff.(Root-Cause Analysis Comprehensive Nursing Paper Sample)

To sum up, Clarion Court Skilled Nursing Facility has in the past provided exceptional patient care; however, the past six months have presented a different picture altogether for the institution. Increasing incidents of medication errors necessitated a root cause analysis which identified several causal factors, including lack of communication and collaboration, distractive environments, and skipping procedures due to time constraints. Recommendations to address the errors are improved interprofessional collaboration and communication, adopting the HALT model and in-service programs, and hiring new staff. Research shows that these strategies are essential for medication administration to reduce errors and improve patient safety outcomes. (Root-Cause Analysis Comprehensive Nursing Paper Sample)


Cutler, S., Morecroft, C., Carey, P., & Kennedy, T. (2018). Are interprofessional healthcare teams meeting patient expectations? An exploration of the perceptions of patients and informal caregivers. Journal of Interprofessional Care33(1), 66-75(Root-Cause Analysis Comprehensive Nursing Paper Sample).

Ghorbanzadeh, M., Gholami, S., Sarani, A., Badeli, F., & Nasimi, F. (2019). The prevalence, barriers to medication error reports, and nurses’ perceptions toward the causes of medication errors in the hospitals affiliated to north Khorasan University of medical sciences, Iran. Iran Journal of Nursing32(117), 58-68(Root-Cause Analysis Comprehensive Nursing Paper Sample).

HALT: The dangers of hunger, anger, loneliness, and tiredness | Rehab. (2021, August 19). Bradford Health Services – Drug and Alcohol Rehabilitation Center.

Harrington, C., Schnelle, J. F., McGregor, M., & Simmons, S. F. (2016). Article Commentary: The need for higher minimum staffing standards in U.S. nursing homes. Health Services Insights9, HSI.S38994.

Samaei, S., Amrollahi, M., Khanjani, N., Raadabadi, M., Hosseinabadi, M., & Mostafaee, M. (2017). Nurses’ perspectives on the reasons behind medication errors and the barriers to error reporting. Nursing and Midwifery Studies6(3), 132(Root-Cause Analysis Comprehensive Nursing Paper Sample).

Walpola, R., Fois, R., McLachlan, A., & Chen, T. (2017). Evaluating the effectiveness of an educational intervention to improve the patient safety attitudes of intern pharmacists. American Journal of Pharmaceutical Education81(1), 5. doi: 10.5688/ajpe8115(Root-Cause Analysis Comprehensive Nursing Paper Sample)

(Root-Cause Analysis Comprehensive Nursing Paper Sample)
(Root-Cause Analysis Comprehensive Nursing Paper Sample)

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