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1Root-Cause Analysis and Safety Improvement PlanKathryn SchreinerSchool of Nursing and Health Sciences, Capella UniversityNURS4020: Improving Quality of Care and Patient SafetyProfessor ScarcellaOctober, 2021
2Root-Cause Analysis and Safety Improvement PlanRoot cause analysis (RCA) is a tool developed to help health care organizations studyevents where undesired outcomes or patient harm occurred. This is then reviewed by acommittee in order to not only identify and address the root causes, but to determine what couldhave been done differently and what changes can be made to prevent this from happening again.Addressing the failure at its source allows for the design and implementation of a solution. Byunderstanding the root cause of an event, we can improve patient safety by preventing futureharm.Look-alike or sound-alike (LASA) medication names are often mistaken for each other. Inthe UK, Between January and March 2018 they accounted for 10.7% of incidents and 63 deaths(Bryan et al., 2020).Medication errors can occur when medications have similar-looking or similar-soundingnames, and/or shared features of product packaging. This paper describes and analyzes a sentinelevent that occurred due to a medication error and will describe an appropriate improvement planusing root cause analysis and evidence-based practices.Analysis of the Root CauseA patient was admitted in the hospital due to anaphylaxis and was prescribedHydroxyzine. The nurse on the floor is flustered after having to deal with a family of anotherpatient and is running behind her scheduled medication administration. In a rush, she providesthe patient their medication, but gives Hydralazine. About 45 minutes later, the patient iscomplaining of dizziness and blurry vision. The nurse assesses the patient and observes thepatient has pale, clammy skin. Upon obtaining the vitals, the patients’ blood pressure isextremely low and is placed in Trendelenburg position and provided fluids. When the nurse

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Term
Summer
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Tags
Root cause analysis, root cause, Care and Patient Safety

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