Introduction
NURS FPX 4035 Assessment 2 focuses on performing a root-cause analysis (RCA) to investigate a safety incident and develop effective prevention strategies. RCA is a systematic method used to identify underlying issues that contribute to adverse events in healthcare settings.
Description of the Safety Incident
For this assessment, the selected incident involves a medication administration error where a patient was given the wrong insulin dosage. In \ Assessment 2, this incident was analyzed due to its serious potential consequences, such as hypoglycemia, and its relevance to patient safety.
Root-Cause Analysis Process
The RCA process involved reviewing the event, collecting detailed data, and interviewing staff members involved. Key contributing factors included miscommunication between healthcare providers, lack of standardized double-check procedures, and staff fatigue. Furthermore, unclear medication protocols increased the risk of errors.
Findings and Underlying Causes
The analysis revealed several root causes, including inadequate staff training, high workload, and unclear responsibilities during medication administration. Moreover, the absence of an effective barcode scanning system contributed to the error. These issues indicated both system-level and individual-level gaps in safety practices.
Action Plan and Recommendations
Based on the RCA findings, I developed an action plan focusing on system improvements and staff education. Recommended actions include implementing barcode medication administration (BCMA), enhancing staff training, and establishing clear communication protocols. Additionally, regular audits and peer reviews will be conducted to monitor adherence.
Expected Outcomes
In NURS FPX 4035 Assessment 2, the expected outcomes include a reduction in medication errors, improved staff accountability, and enhanced patient safety. Furthermore, the action plan promotes a culture of continuous learning and proactive error prevention across the healthcare team.
Conclusion
Conducting a root-cause analysis is an essential strategy for improving patient safety and preventing future adverse events. Through this assessment, I gained valuable skills in analyzing safety incidents and developing effective, evidence-based solutions for long-term quality improvement.