Capella 4035 Assessment 2

Capella 4035 Assessment 2

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

This document offers a structured framework for conducting a Root-Cause Analysis (RCA) to evaluate sentinel events. While not every element will apply in all cases, the objective is to explore all potential contributors to identify the root cause(s) and develop risk reduction strategies. A sentinel event is an unexpected occurrence involving patient safety, not directly tied to the patient’s illness or condition. These events often have devastating consequences for both patients and healthcare teams. By thoroughly examining such incidents, healthcare organizations aim to enhance system performance and prevent recurrence.

Understanding What Happened

To understand the incident thoroughly, it’s essential to examine the sequence of events, the individuals involved, and the surrounding circumstances. In the current scenario, a patient was administered the wrong medication. This error was linked to several factors: inadequate interprofessional communication, incomplete medication history documentation, non-standardized safety procedures, and excessive staff workload. As a result, the patient suffered adverse effects, leading to delayed recovery and increased healthcare costs. The event also created added strain on healthcare providers and incurred financial implications for the hospital due to prolonged care and corrective actions.

Why Did It Happen?

Human Factors

• Communication Gaps: Ineffective communication among clinical staff contributed to the medication error.
• Fatigue: Excessive workloads led to reliance on memory, increasing the likelihood of prescribing or dosing mistakes.
• Training Deficiencies: Staff had insufficient training on new medications, safe administration, and drug interactions.

System Factors

• Process Inefficiencies: Absence of consistent medication reconciliation protocols heightened the risk of errors.
• Technology Limitations: Lack of integrated alert systems and barcode scanning allowed preventable mistakes to occur.
• Poor Documentation: Incomplete records of patient medications facilitated drug interaction risks.

Organizational Culture

• Safety Norms: Weak safety culture allowed variability in following best practices.
• Leadership Involvement: Limited engagement from leadership in promoting medication safety through training or support tools.

Society and Culture

• Cultural Sensitivity: Patients with limited health literacy or language barriers were not fully informed, reducing their capacity to engage in their care.

Deviation from Protocols or Standards

Procedures and Policies The organization failed to consistently apply Medication Decision Support Systems (MDSS) and other electronic safeguards.

Documentation Shortcomings Key data such as allergies and medication history were not effectively communicated during handovers. Furthermore, many medication reconciliation forms and adverse reaction reports were incomplete or missing from the patient’s medical records.

Who Was Involved?

Clinical Staff Nurses and pharmacists were responsible for accurate medication administration and patient education.

Supervisory Personnel Unit supervisors were expected to enforce medication protocols and ensure adherence to documentation standards.

Communication Breakdowns

Interdisciplinary Communication Essential information regarding dosage changes and possible drug interactions was not properly shared between care teams.

Patient-Provider Communication Patients were inadequately informed about the medications they received, associated risks, and the need for compliance.

Contributing Factors

Physical Environment Disorganized medication storage, inadequate labeling, and lack of scanning equipment compromised safety.

Staffing Constraints Understaffing led to hurried rounds, reducing time available for proper verification.

Competency Gaps Staff lacked necessary training in handling high-alert medications and using advanced prescribing technologies.

Role of Policies and Procedures

Policy Adherence There was inconsistent adherence to existing safety protocols, leading to operational gaps.

Policy Clarity Medication-related procedures were poorly defined and not effectively embedded in clinical workflows.

Failures in Monitoring and Surveillance

Vital Signs Monitoring High-risk patients were not consistently monitored for early signs of adverse reactions.

Alarm Fatigue Frequent, nonspecific alerts were often disregarded, reducing the system’s effectiveness.

Lessons Learned and Quality Improvement

Lessons Learned Standardized training programs, consistent protocols, and effective communication structures are vital to reducing errors.

Quality Improvement Initiatives The implementation of MDSS and other evidence-based tools can significantly improve safety outcomes (Syrowatka et al., 2024).

Enhancing Patient Safety

Risk Mitigation Strategies Standardize reconciliation at all care transitions and integrate advanced alert systems.

Staff Education and Training Offer continuous education on pharmacology, safe practices, and high-risk drugs.

Feedback and Reporting Culture Promote a non-punitive reporting environment to encourage learning from errors and near-misses.

---

Root Cause(s) of the Sentinel Event

The table below outlines the root causes and contributing factors identified during the analysis. Each issue is categorized according to relevant influencing factors.

Issue	Description	Root Cause Category
Incomplete Medication Reconciliation	Failure to use standardized tools led to missing or incorrect medication data.	HF-C (Human Factor – Communication)
Inadequate Communication During Handover	Miscommunication led to omissions in allergy documentation and incorrect dosages.	HF-C (Human Factor – Communication)
Staff Fatigue	Scheduling demands resulted in fatigue, increasing the risk of errors.	HF-F/S (Human Factor – Fatigue/Scheduling)
Lack of Interdisciplinary Training	Staff were unprepared to handle complex medication protocols.	HF-T (Human Factor – Training)
Environmental Shortcomings	Inadequate equipment and disorganized workspaces impaired safe administration.	E (Environment/Equipment)
Policy and Procedure Gaps	Ambiguous or poorly enforced policies contributed to inconsistencies in medication practices.	R (Rules/Policies/Procedures)
Patient Barriers	Cultural and linguistic challenges limited patient understanding and advocacy.	B (Barriers)

Abbreviations Used:

• HF-C = Human Factor – Communication
• HF-T = Human Factor – Training
• HF-F/S = Human Factor – Fatigue/Scheduling
• E = Environment/Equipment
• R = Rules/Policies/Procedures
• B = Barriers Here is the fully rephrased content in paragraph format and a corresponding row-and-column table, with APA formatting preserved and all headings structured at three levels (as per your request). The text is reworded to avoid plagiarism while retaining the original meaning.

Application of Evidence-Based Strategies

Identification of Best Practice Strategies to Address Medication Safety

Medication errors (MEs) continue to pose a serious challenge to patient safety, often leading to adverse drug reactions, extended hospital stays, and increased healthcare costs. Studies show that medication errors impact millions globally and account for substantial, yet preventable, financial burdens—such as an estimated £98.5 million in the UK annually (Elliott et al., 2024). Key contributors to these errors include a lack of consistent medication reconciliation, ineffective interprofessional communication, and insufficient training on high-alert medications.

Azadi and García-Peñalvo (2025) identified that integrating Medication Decision Support Systems (MDSS) within Electronic Health Records (EHRs) significantly reduces both prescribing and administration errors. These systems offer real-time alerts for drug interactions, allergies, and duplicate prescriptions, thereby enhancing medication safety and compliance with clinical guidelines. Moreover, communication breakdowns during shift changes have been noted as a critical risk point. Alizadeh-Risani et al. (2024) demonstrated that implementing structured communication protocols such as SBAR (Situation, Background, Assessment, Recommendation) significantly improved the accuracy of medication information handover. Trained nurses documented medications more reliably and promptly reported discrepancies compared to untrained peers.

Additionally, Ahmed and Rahman (2025) emphasized the role of ongoing education for healthcare staff, particularly nurses, to enhance knowledge in pharmacology and medication administration. Continuous training initiatives were linked with higher vigilance in identifying and correcting dosage errors. Lastly, Ravi et al. (2022) stressed the importance of interprofessional collaboration between nurses and pharmacists. They found that joint decision-making and multidisciplinary rounds decreased medication discrepancies by 32%. Together, these strategies—teamwork, technological integration, structured communication, and ongoing education—are essential for reducing medication errors and improving care quality.

Application of Strategies to Address Sentinel Events

The discussed strategies can be directly applied to reduce medication-related sentinel events. First, the integration of MDSS into EHR platforms will enable real-time validation of prescriptions, preventing high-risk errors arising from incomplete or rushed documentation. Second, structured handover protocols like SBAR during shift changes can mitigate communication lapses by ensuring essential medication data is consistently conveyed. Third, continuous training programs will enhance staff competence in recognizing and preventing errors, particularly for new or high-alert medications. Lastly, fostering collaboration between nurses and pharmacists will facilitate early detection and resolution of prescription discrepancies, thereby enhancing patient outcomes and reducing sentinel events.

---

Safety Improvement Plan

Future Preventive Actions and Control Strategies

Root Cause or Contributing Factor	Proposed Action	Strategy Type
Incomplete Medication Reconciliation	– Implement standardized reconciliation protocols at each care transition – Integrate EHR alerts for missing or conflicting drug data	Control (C)
Ineffective Shift Communication	– Mandate use of SBAR for all handovers – Strengthen interdisciplinary communication between care providers	Control (C)

Policy, Process, and Professional Development Modifications

To address the root causes of medication-related safety events, several new measures will be introduced. A standardized policy will mandate complete medication reconciliation at all care transitions—admission, transfer, and discharge—using a validated checklist. This will ensure consistency in documentation and prevent omissions or duplications. Simultaneously, SBAR will be formally adopted as the universal handover method to improve clarity and consistency during nurse shift changes.

Staff development will also be prioritized. All clinical staff will undergo quarterly training sessions focused on pharmacological updates, safe administration practices, and the use of MDSS tools. The EHR system will be upgraded to include features such as real-time reconciliation prompts, drug interaction warnings, and allergy alerts. Lastly, monthly interdisciplinary case review meetings involving physicians, nurses, and pharmacists will be organized to evaluate medication safety trends and assess adherence to new policies.

Goals, Outcomes, and Implementation Timeline

Goal	Desired Outcome	Timeline
Standardize medication reconciliation	Achieve 100% accurate medication documentation at care transitions	Months 1–2
Enhance shift-to-shift communication	Achieve 100% SBAR compliance during medication-related handovers	Months 3–4
Improve staff medication safety knowledge	≥90% of staff complete training on safe practices	Months 5–7
Reduce medication errors	30% reduction in reconciliation- and handover-related medication errors	By Month 12

---

Existing Organizational Resources

Assessment and Leveraging of Available Resources

To ensure the success of the proposed safety improvement plan, both existing and new resources will be utilized. EHR systems will be enhanced to include features that support reconciliation, allergy checks, and interaction alerts. Staff training modules—either developed in-house or procured from reputable sources—will be implemented to improve understanding of safe medication practices and effective communication via SBAR.

The use of standardized SBAR templates (digital or paper-based) will be enforced across all units to foster consistency. Pharmacists already on staff will be engaged more actively in cross-verification processes, particularly during high-risk transitions. The hospital’s Quality Improvement (QI) team will track compliance, monitor medication error trends, and offer continuous feedback. Clinical Decision Support Systems (CDSS) already integrated within the EHR will be enhanced to improve real-time verification capabilities. Strong leadership support will be crucial, including allocation of funds, adjustments to workflows, and overall policy enforcement.

---

References

Ahmed, R., & Rahman, T. (2025). Enhancing medication safety: The role of community and hospital pharmacists in modern healthcare systems. Deleted Journal, 2(3), 328–355. https://doi.org/10.56778/rjhs.v2i3.418

Alizadeh-Risani, A., Mohammadkhah, F., Pourhabib, A., Fotokian, Z., & Khatooni, M. (2024). Comparison of the SBAR method and modified handover model on handover quality and nurse perception in the emergency department: A quasi-experimental study. BMC Nursing, 23(1). https://doi.org/10.1186/s12912-024-02266-4

Capella 4035 Assessment 2

Azadi, A., & García-Peñalvo, F. J. (2025). A synergistic bridge between human–computer interaction and data management within CDSS. Data, 10(5), 60. https://doi.org/10.3390/data10050060

Elliott, R., Camacho, E., Campbell, F., Jankovic, D., St James, M., Kaltenthaler, E., Wong, R., Sculpher, M., & Faria, R. (2024). Prevalence and economic burden of medication errors in the NHS in England: Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. https://orda.shef.ac.uk/articles/report/PREVALENCE_AND_ECONOMIC_BURDEN_OF_MEDICATION_ERRORS_IN_THE_NHS_IN_ENGLAND_Rapid_evidence_synthesis_and_economic_analysis_of_the_prevalence_and_burden_of_medication_error_in_the_UK/25218950/1/files/44544338.pdf

Capella 4035 Assessment 2

Ravi, P., Pfaff, K., Ralph, J., Cruz, E., Bellaire, M., & Fontanin, G. (2022). Nurse-pharmacist collaborations for promoting medication safety among community-dwelling adults: A scoping review. International Journal of Nursing Studies Advances, 4(4), 100079. https://doi.org/10.1016/j.ijnsa.2022.100079