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Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN1Root-Cause Analysis and Safety Improvement Plan for Medication ErrorsName:School:Course:Tutor: Date:
ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN2Root-Cause Analysis and IntroductionThe root-cause analysis (RCA) is a tool used to study and investigate the causes underlying a patient safety incident, such as a medication error (Rezaei, 2019). The RCA tool is crucial in identifying problem areas that need to change towards improving patient experience and outcomes. The RCA tool and process ends with the formulation of the recommendations aimed at increasing patient safety. The incidents that typically warrant the root-cause analysis application include medication errors (Rezaei, 2019). Applying the RCA tool to study the causes of medication errors at the HRI Clinic is crucial, noting the alarming numbers of injuries, lengthened hospital stay, and death that the adverse events cause in American hospitals (Mazer and Nabhan, 2019). For example, Mazer and Nabhan (2019) note that medication errors cause over 200,000 deaths every year in America, indicating that many root causes and factors play a role in the events, warranting exploring these dynamics at the organizational level. The root cause analysis of medication errors among patients in the HRI Clinic covered the ten wards, including the pediatric wards. The report based on the assessment describes and analyzes the medication errors reported, the underlying causes, the major players, and applies evidence-based best practices and strategies to minimize these adverse events. In addition to offering findings on the causes of medication errors, the report includes an evidence-based plan for improving patientsafety levels and crucial organizational resources to improve safety. Analysis of the Root Causes of Medication ErrorsEvery time a healthcare service provider such as a nurse, physician, or pharmacist offers care to patients, they can unintentionally inflict injury or cause harm due to adverse events such as disease misdiagnosis and medication errors. Gates et al. (2019) report that medication errors happen in 10-20 percent of medication orders, depending on the adverse event's definition, for
ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN3example, delayed drug administration. However, the study indicated that serious medication errors are 5 percent of all medication administrations. Out of the total number of medication errors, less than 10 percent have the potential to cause injury, and only 1 percent cause patient injury or death (Gates et al., 2019). In the HRI Clinic case, management reports showed that seven medication errors happen for every 100 medical administrations, indicating a number above the acceptable average for a healthcare organization. The data on the number of medication errors reported at the clinic were collected over the past thirty days, using direct and non-participant tracking of the preparation and delivery of medications to patients. Direct observation was useful because it reflected the actual causes of medication errors. Similarly, non-