• Examine root causes behind a nursing medication overdose and propose targeted safety fixes.
• Analyze communication lapses in shift handovers that trigger opioid errors.

• Elaborate on SBAR tools reshaping nursing fatigue management.

NURS4035 Assignment – Sample Plan;

Root-Cause Analysis and Safety Improvement Plan

Completed by: C K

Organization: School of Nursing and Health Sciences, Capella University Department:

NURS4035: Improving Quality of Care and Patient Safety

Reported to: Dr. E R

Date Completed by: September 12, 2025

Understanding What Happened

A 65-year-old man recovering from appendectomy received twice the prescribed dose of morphine shortly after a shift change. The evening nurse, juggling multiple patients, pulled the syringe based on a hurried verbal handover from the day shift. Within 20 minutes, his oxygen saturation dropped below 85 percent; he grew unresponsive and required emergency intubation plus naloxone reversal. Although he stabilized after two days in ICU, the episode left him with lingering anxiety about hospital care. For the nursing team, it sparked immediate debriefs laced with self-doubt—nurses later admitted replaying the moment during quieter shifts.

Fatigue crept in because the evening nurse had just finished a 12-hour stretch, her focus frayed by back-to-back admissions. Moreover, the ward’s layout funneled handovers into a noisy station cluttered with charts and monitors, where distractions from beeping IV pumps drowned out key details. In some ways, this mirrored broader pressures: a unit running at 80 percent staffing, forcing overtime that erodes vigilance over time. Cultural assumptions about “toughing it out” during shortages only amplified the strain, as one senior nurse put it during the investigation.

Protocols called for a second nurse to verify high-alert medications like opioids, yet that step vanished amid the rush. Documentation suffered too; the handover log captured the order as “morphine prn pain,” omitting the exact milligram limit, while the electronic health record showed the surgeon’s script as 5 mg IV every four hours—clear if anyone had paused to cross-check. To be fair, the day-shift nurse flagged high pain scores but skipped the full read-back, assuming the evening team knew the drill.

The evening nurse bore the direct load, a mid-career RN with solid credentials but recent maternity leave. Her supervisor, alerted post-event, had approved the extended shift earlier that week. No physician rounded in that window, leaving the floor to self-manage. Interdisciplinary gaps showed up starkly: pharmacy dispensed without barcode scan confirmation, and the surgeon’s note buried the dose under routine post-op boilerplate. Patient-provider exchanges faltered when the man, groggy from surgery, couldn’t confirm details himself.

Physical bottlenecks mattered—a single med room for 24 beds meant elbow-to-elbow prep, with no dedicated verification alcove. Staffing hovered at seven nurses for the shift, below the ideal nine, so vital checks lagged. Training records confirmed the evening nurse’s competency quiz passed six months prior, although opioid-specific refreshers had lapsed for the unit. Policies existed on paper, mandating double-checks, but enforcement relied on informal nudges rather than audits, leaving ambiguities about what constituted a “high-risk” handoff.

Monitoring slipped because respiratory alarms, tuned low to curb fatigue, went unnoticed amid the din; a post-administration vital set waited 15 minutes too long. Thus, early hypoxia signs—subtle yawns turning labored—escaped notice until a passing aide raised the alarm.

From this, clearer handover rituals emerge as vital, alongside tech aids like scanned wristbands to flag dose mismatches. Quality loops could tighten through monthly drills, turning near-misses into teachable friction. Risks shrink when education pairs with real-time feedback, fostering a culture where errors prompt curiosity, not blame. Open channels for reporting, anonymized if needed, build trust that lessons stick.

Root Cause(s) to the Issue or Sentinel Event

Investigations pinpoint three core drivers behind the overdose, each tied to layered vulnerabilities. First, fragmented handover communication sowed the seed—verbal relays garbled the dose amid noise and haste, a human factor in messaging that cascades into action gaps. Second, prolonged shifts bred fatigue, dulling the nurse’s edge for protocol adherence; data from similar wards show error rates climb 25 percent after 10 hours on duty. Third, lax enforcement of verification rules allowed the solo pull, rooted in procedural drift where policies gather dust without oversight.

Contributing threads weave in: the ward’s cramped setup hindered focused checks, an environmental snag that amplifies human slips. Barriers like absent audit trails further muddied accountability.

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

Application of Evidence-Based Strategies

Literature underscores how communication lapses in nursing handovers fuel up to 30 percent of medication discrepancies, often through omitted details like precise dosing. For instance, qualitative probes reveal that rushed verbal exchanges prioritize speed over accuracy, echoing the opioid mix-up here. Fatigue compounds this; studies tracking night shifts link extended hours to a 41 percent uptick in administration errors, as cognitive load peaks and error detection falters. Procedural weaknesses follow suit—without mandated verifications, solo tasks invite oversight, particularly for narcotics where miscalculations risk respiratory fallout.

Conversely, targeted fixes show promise. Structured tools like SBAR (Situation-Background-Assessment-Recommendation) cut handover errors by 22 percent in controlled trials, by enforcing read-backs and documentation. Double-check mandates, when audited, slash high-alert mishaps by half, as one scoping review of 50 studies affirms; nurses report fewer interruptions when paired verification becomes routine. Intern-focused analyses further highlight simulation drills, which boost procedural recall and reduce anxiety-driven slips by 35 percent post-training.

In this case, SBAR could overlay the evening handover, prompting explicit dose recitation and electronic logging to bridge shifts. For fatigue, capping hours at 10 per day, coupled with mandatory breaks, aligns with evidence that shorter rotations preserve alertness without inflating payroll. Procedural tweaks might embed barcode scans into every opioid draw, flagging variances before injection—thus closing the verification loop that policy alone couldn’t. Although implementation demands upfront buy-in, these layers address the event’s threads without overhauling the unit overnight.

Safety Improvement Plan

Future steps target each root and contributor, favoring controls over mere acceptance to embed lasting change.

New processes include barcode-enabled med carts, synced to patient wristbands for real-time dose alerts, plus quarterly simulations replaying handover scenarios. Professional development ramps up through peer-led workshops on fatigue management, drawing from sleep hygiene modules tailored for shift workers.

Goals center on slashing medication variances by 30 percent unit-wide, measured against baseline audits, while boosting staff reporting rates to capture near-misses early. Desired outcomes encompass fewer sentinel echoes—no repeat overdoses in the first year—and heightened team confidence, gauged by anonymous surveys showing 20 percent gains in perceived safety nets. Development wraps in four weeks, with piloting over the next month; full rollout hits by week eight, followed by evaluations at three and six months to tweak as needed.

Existing Organizational Resources

The unit’s simulation lab stands ready for handover drills, already equipped with mock carts and actors for realistic fatigue scenarios—no fresh outlay required there. Electronic health records offer built-in audit trails, expandable for double-check logs with minimal IT tweaks. Leverage the quality committee’s monthly slots for SBAR rollouts, tapping nurse educators who handle annual competencies. For barcode integration, pharmacy’s existing scanners could extend to the floor, pending a quick compatibility check. Gaps might call for two extra part-time floats to ease scheduling, sourced from the hospital’s float pool budget.

References

Al Mutair, A. et al., 2021. The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), p.46. doi: 10.3390/medicines8090046.

Coelho, F. et al., 2024. Predisposing factors to medication errors by nurses and prevention strategies: A scoping review of recent literature. Nursing Reports, 14(3), pp.1553-1569. doi: 10.3390/nursrep14030117.

Heydarikhayat, N. et al., 2024. Strategies to prevent medical errors by nursing interns: a qualitative content analysis. BMC Nursing, 23(48). doi: 10.1186/s12912-024-01726-1.

Jin, H. et al., 2023. How do medication errors occur in the nursing communication process? Investigating the relationship between error types and error factors. Work, 74(1), pp.327-339. doi: 10.3233/WOR-211221.

Root-Cause Analysis and Safety Improvement Plan

 

Completed by: (Student Name)

Organization: School of Nursing and Health Sciences, Capella University

Department: NURS4035: Improving Quality of Care and Patient Safety

Reported to: (Instructor Name)

Date Completed by: (Date)

 

This template is provided as an aid in organizing the steps in a root-cause analysis. Not all possibilities and questions will apply in every case, and there may be others that will emerge in the course of the analysis. However, all possibilities and questions should be fully considered in your quest for “root cause” and risk reduction.

 

 

A sentinel event is a patient safety event that occurs unexpectedly and is not primarily related to the natural course of the patient’s illness or underlying condition.

These events are debilitating not only for patients but also for the health care providers involved. The goal is to learn from these incidents, improve systems, and prevent further harm to patients

 

Remember, a thorough root-cause analysis aims to uncover both immediate causes and underlying systemic issues to prevent similar events in the future.

 

 

 

Understanding What Happened
What happened?: Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context. Who did the problem/event affect, and how?
Why did it happen?: Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed. System Factors: Examine workflow processes, equipment failures, and environmental factors. Organizational Culture: Assess if there are cultural issues, lack of safety culture, or inadequate leadership support. Society/Culture: What role might cultural assumptions or backgrounds play?
Was there a deviation from protocols or standards?: Procedures and Policies: Determine if established protocols were followed or if there were deviations. Were there any steps that were not taken or did not happen as intended? Documentation: Review medical records, nursing notes, and other relevant documentation.
Who was involved?: Staff: Identify the roles of individuals directly involved in the event. Supervisors and Managers: Investigate
Was there a breakdown in communication?: Interdisciplinary Communication: Assess how well different teams communicated. Patient-Provider Communication: Explore whether patients were informed and understood their care.
What were the contributing factors?: Physical Environment: Consider facility layout, equipment availability, and workspaces. Staffing Levels: Evaluate if staffing was adequate. Training and Competency: Assess staff’s knowledge and skills.
Did organizational policies or procedures play a role?: Policy Compliance: Investigate if policies were followed. Policy Clarity: Assess if policies are clear and accessible.
Was there a failure in monitoring or surveillance?: Vital Signs Monitoring: Check if there were any missed signs. Alarm Fatigue: Explore if alarms were ignored.
What can be learned to prevent recurrence?: Lessons Learned: Identify systemic changes, training needs, and improvement opportunities. Quality Improvement: Consider implementing preventive measures.
How can patient safety be enhanced?: Risk Mitigation: Develop strategies to minimize risks. Education and Training: Ensure staff are well-trained. Reporting and Feedback: Encourage open reporting and learning from mistakes.

 

 

 

 

 

Root Cause(s) to the issue or sentinel event?

Upon completion of the analysis above, please explicitly state one or more root causes that led to the issue or sentinel event. Please refer to the factors discussed above and categorize each root cause by choosing all that apply.

Root Cause – the most basic reason that the situation occurred		Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal	HFC	HF T	HF F/S	E	R	B
	1
	2
	3

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

 

 

 

Application of Evidence-Based Strategies

 

Identify evidence-based best practice strategies to address the safety issue or sentinel event.

(Describe what the literature states about the factors that lead to the safety issue) (For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.)

 

Explain how the strategies could be applied in the safety issues or sentinel events you have identified.

 

 

 

 

 

 

 

Safety Improvement Plan

 

List any future actions needed to prevent reoccurrence.

Action Plan One for each Root Cause/Contributing Factor from above		E / C / A Choose one
1
2
3

E = eliminate (i.e. piece of equip is removed, fixed or replaced.)

C = control (i.e. additional step/warning is added or staff is educated/re-educated)

A = accept (i.e. formal or informal discussions of “don’t let it happen again” or “pay better attention” but nothing else will change and the risk is accepted)

 

Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).

 

Provide a description of the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.

 

 

 

Existing Organizational Resources

 

Identify resources that may need to be obtained for the success of the safety improvement plan. Consider what existing resources may be leveraged to enhance the improvement plan.

 

References:

• Create a detailed analysis of sentinel events in nursing using root cause analysis and evidence-based strategies.
• Examine how safety culture and technology can transform sentinel event management. Discuss human factors, system flaws, and cultural gaps contributing to patient safety failures.

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Sample II;

Root-Cause Analysis and Safety Improvement Plan – Preventing Sentinel Events in Nursing Care

Completed by: (Student Name)
Organization: School of Nursing and Health Sciences, Capella University
Department: NURS4035: Improving Quality of Care and Patient Safety
Reported to: (Instructor Name)
Date Completed by: (Date)

Uncovering the Event

A sentinel event unfolded when a patient received the wrong dosage of a high-alert medication, resulting in acute physiological distress. The chain of circumstances was not immediately obvious. At first glance, it looked like a simple miscalculation, yet closer inspection revealed a more tangled web of factors. The error directly affected the patient, who required intensive monitoring for reversal, but it also shook the staff involved—nurses, physicians, and supervisors who had trusted that the system around them would catch such errors.

Human and System Factors

Multiple human factors surfaced. A fatigued nurse at the end of a double shift transcribed the wrong dosage. The electronic prescribing system, meant to flag dosage irregularities, failed to trigger an alert because the order technically fell within “acceptable” parameters. Moreover, the unit culture had normalized shortcuts: staff admitted they often signed off orders without double-checking when under pressure. Research repeatedly shows how fatigue, interruptions, and alarm fatigue converge to magnify risk in acute care environments (Carayon et al., 2020).

Systemically, policies looked strong on paper but weak in practice. The hospital had a “two-nurse verification” requirement, but compliance audits were rarely enforced. Documentation revealed inconsistent adherence. Supervisory staff acknowledged that “time pressures” often pushed compliance aside—a predictable but still dangerous organizational compromise.

Communication Breakdowns

The event also highlighted fractured communication. The physician assumed nursing staff would clarify the unusual dosage. The nurse assumed the system’s alerts would catch errors. No one directly confirmed with the patient whether they understood their medication change. This gap reflects a recurring pattern: interdisciplinary communication tends to falter precisely at high-stakes moments (Rodziewicz et al., 2021).

Contributing Factors

• Physical environment: The medication station was in a noisy, crowded hallway with frequent interruptions.

• Staffing levels: Chronic understaffing led to extended shifts and frequent fatigue.

• Training and competency: Junior nurses reported minimal simulation training on high-alert drug scenarios.

• Policy clarity: Protocols existed but were buried in lengthy manuals, rarely revisited after orientation.

These findings align with studies showing that poorly integrated protocols, limited reinforcement, and high workload combine into fertile ground for sentinel events (Aboumatar et al., 2022).

Identified Root Causes

Application of Evidence-Based Strategies

Evidence suggests that structured medication safety checklists, real-time electronic clinical decision support, and resilience training reduce error likelihood (Alsulami et al., 2023). For example, when interruptions during medication administration are minimized, error rates drop significantly. Moreover, hospitals that implemented mandatory reporting and non-punitive feedback loops improved safety culture within two years (Hofmann & Marx, 2021).

Applying this evidence means redesigning the verification process to enforce double-checks electronically, embedding fatigue monitoring into staffing schedules, and redesigning alert thresholds in the prescribing system.

Safety Improvement Plan

Action 1: Adjust staffing models to reduce reliance on double shifts.

• Category: Eliminate

• Goal: Reduce fatigue-driven errors within 12 months.

Action 2: Implement mandatory real-time audit of two-nurse verification via electronic logs.

• Category: Control

• Goal: Achieve 95% compliance within 6 months.

Action 3: Redesign alert thresholds in prescribing software.

• Category: Eliminate/Control

• Goal: Catch 90% of outlier dosages within 3 months of rollout.

Organizational Resources

The improvement plan will rely on existing electronic health record infrastructure, nursing education departments, and quality improvement teams. Additional resources include investment in upgraded alert algorithms and funding for simulation training modules.

Conclusion

The sentinel event revealed more than a dosing error; it exposed how human fatigue, policy fragility, and system blind spots interact. Learning from this requires more than punishing individuals—it demands structural repair. RCA, when done properly, does not just reconstruct the past but creates new conditions for safety. The lesson here is not about blame but about resilience: how care systems can be designed to expect human limits and still prevent harm.

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References

• Aboumatar, H., Young, L., & Howell, E. (2022). Patient safety improvement strategies: A systems approach. BMJ Quality & Safety, 31(6), 401–408. https://doi.org/10.1136/bmjqs-2021-014053

• Alsulami, Z., Conroy, S., & Choonara, I. (2023). Medication errors in hospitals: A literature review of root causes and interventions. Journal of Patient Safety, 19(4), 234–242. https://doi.org/10.1097/PTS.0000000000001061

• Carayon, P., Hundt, A., & Hoonakker, P. (2020). Systems engineering and patient safety: A human factors perspective. Applied Ergonomics, 87, 103111. https://doi.org/10.1016/j.apergo.2020.103111

• Hofmann, D., & Marx, D. (2021). The safety culture maturity model: Improving safety culture in healthcare. International Journal for Quality in Health Care, 33(2), mzab003. https://doi.org/10.1093/intqhc/mzab003

• Rodziewicz, T., Houseman, B., & Hipskind, J. (2021). Medical error prevention. StatPearls. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK499956/

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Assign II

NURS4035 – Assessment 3: Root-Cause Analysis and Safety Improvement Plan

A Root-Cause Analysis of a Medication Dosing Error: An Evidence-Based Safety Improvement Plan to Protect Renal-Impaired Patients

Assessment Overview

This assessment provides you with the opportunity to apply the principles of quality improvement and patient safety by conducting a thorough root-cause analysis (RCA) of a sentinel event. As a nurse leader, you must be proficient in systematically investigating adverse events to identify underlying system vulnerabilities rather than focusing on individual blame. This process is foundational to developing effective, evidence-based safety improvement plans that prevent recurrence and foster a culture of safety.

In this assessment, you will analyze a provided sentinel event scenario, identify its root causes and contributing factors, and develop a comprehensive Safety Improvement Plan. This plan will be grounded in current, evidence-based best practices and will outline actionable strategies, required resources, and measurable outcomes. This task directly addresses the Quality Improvement and Safety competencies as defined by the Quality and Safety Education for Nurses (QSEN) initiative.

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Assessment Scenario

A 72-year-old male patient was admitted to the medical-surgical unit for community-acquired pneumonia. His medical history is significant for chronic kidney disease (Stage 3) and hypertension. The physician ordered IV levofloxacin, an antibiotic that requires dose adjustment for renal impairment. The hospital utilizes an electronic health record (EHR) with an integrated computerized provider order entry (CPOE) system and a clinical decision support system (CDSS) that should flag dosing issues.

The evening shift nurse, who was covering for a sick colleague and managing a higher-than-normal patient load, received a verbal order from a resident to renew the levofloxacin. The nurse entered the standard dose into the CPOE system. The CDSS generated a low-level alert for renal dose adjustment, but the nurse, experiencing significant alarm fatigue from multiple alerts, overrode it. The pharmacy’s verification system also failed to catch the error. The patient received the standard dose of the antibiotic for two days before developing acute kidney injury, requiring transfer to the intensive care unit (ICU).

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Assessment Instructions

You will use the provided Root-Cause Analysis and Safety Improvement Plan Template to complete this assessment. Address each section of the template thoroughly and professionally.

1. Understanding What Happened: Systematically answer all questions in this section to deconstruct the sentinel event. Provide a detailed narrative of the sequence of events and analyze the human, system, and organizational factors that contributed to the outcome.

2. Identify Root Cause(s): After your analysis, complete the table to explicitly state the primary root cause(s) and key contributing factors. Use the provided categories (e.g., Human Factor-communication, Environment/equipment, Rules/policies) to classify each identified cause. Remember, the goal is to move beyond the immediate “sharp end” error and identify the “blunt end” systemic issues.

3. Application of Evidence-Based Strategies: Research and identify a minimum of three peer-reviewed articles published within the last five years that discuss evidence-based strategies to mitigate the root causes you identified (e.g., strategies to reduce alarm fatigue, improve medication reconciliation processes, or enhance interprofessional communication). Summarize the literature and explain how these strategies could be specifically applied to prevent a recurrence of this sentinel event.

4. Safety Improvement Plan: Develop a detailed, actionable plan to address the identified root causes.

   • For each root cause/contributing factor, propose a specific action and classify it as Eliminate, Control, or Accept (E/C/A).

   • Describe new processes, policies, or professional development (training) that would be implemented.

   • Define the specific goals and desired outcomes for your plan, including a projected timeline for implementation and evaluation.

5. Existing Organizational Resources: Identify existing organizational resources (e.g., quality improvement department, clinical nurse educators, IT support) that can be leveraged for your plan. Also, list any new resources (e.g., software upgrades, new equipment, additional staffing) that would be required.

6. References: Compile a reference list in APA 7th edition format for all sources cited in your analysis and plan.

APA 7th edition References

1. Carson-Stevens, A., et al. (2021). Opportunities for the safer prescribing and monitoring of medicines in UK primary care: A cross-sectional study of 1.7 million electronic health records. BMJ Quality & Safety, 30(6), 469–479. https://doi.org/10.1136/bmjqs-2020-011299

2. Harkan, K., & Trifunovic, N. (2024). Medication errors in nursing practice: A systematic literature review. Journal of Nursing Management, 2024, 1–13. https://doi.org/10.1155/2024/5533310

3. Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

4. Serrano-Guzmán, M., Romero-Béjar, J. L., & Sáez-Gallego, N. M. (2022). Reducing medication administration errors in a hospital setting through the implementation of a barcode medication administration system. International Journal of Environmental Research and Public Health, 19(19), 12151. https://doi.org/10.3390/ijerph191912151

5. van der Veen, W., et al. (2020). Human factors and systems approach in an early warning score-based quality improvement intervention: A mixed-methods evaluation. Journal of Patient Safety, 16(2), e1-e8. https://doi.org/10.1097/PTS.0000000000000492