NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan


NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan


Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name


Root-Cause Analysis and Safety Improvement Plan

This assessment highlights the issue of patient identification errors prevailing in Arnold Plamer Hospital. This hospital is dedicated to serving children, particularly providing pediatric healthcare services. In this hospital, the emerging patient-identification errors have impacted the health of many children. This paper will delve into root-cause analysis of misidentified patients and errors in patient identification. Furthermore, the safety improvement plan will be developed to address the growing issue.

Analysis of the Root Cause

In Arnold Palmer Hospital for Children, one fine day, two pediatric patients named Julia and Jenny came for vaccination. Their identification bracelets were mistakenly swapped, and Julia received the vaccinations intended for Jenny and vice versa. The nurse administering the vaccinations detected the error when Julia’s medical history did not match the Electronic Health Records (EHR) information. The nurse realized the patient’s identification did not match the digital records, prompting further investigation. This misidentification of patients affected both patients as Julia received vaccines that were not suited to her medical condition and experienced some allergic reactions as adverse effects. Similarly, Jenny was at risk of contracting diseases due to missed vaccinations, which her health condition required. Additionally, this incident caused anxiety and distress for the families involved, eroding trust in healthcare systems.

The standard protocol for patient identification during vaccination needed to be followed. The nurse did not verify the patient’s identity by cross-checking identification bracelets and EHR data to execute the further vaccination procedure properly. Furthermore, there needed to be more communication between the administrative staff responsible for assigning patient identification bracelets and the nursing staff responsible for administering the vaccinations (Romano et al., 2021).

Moreover, the hospital’s vaccination department’s high workload and fast-paced nature must have contributed to the oversight and resulted in this event. Lastly, the EHR system failed to raise an alert for a mismatch in patient identification, highlighting a potential flaw within the technology and requiring further upgrades and feature installation (Riplinger et al., 2020). Hence, the root-cause analysis indicates the procedural breakdowns, communication gap, human and environmental errors, and the need for an upgraded EHR system with better-aligned features.

Application of Evidence-Based Strategies

Patient identification errors impact patient safety and require implementing evidence-based strategies to ensure patient safety by delivering correct care treatments to the right patients. These strategies include using a Barcoding System to correctly identify the patients for medication administration and other therapies such as surgeries. The barcode system allows healthcare professionals to give a patient a specific barcode as an identifier in the form of a wristband and deliver care treatments based on the barcode allotted (Barakat & Franklin, 2020). One example of this system is Barcode Medication Administration, in which the barcode of a patient’s wristband is matched with a barcode on the medication to administer the correct medication to the right patient without making an error in patient identification (Owens et al., 2020).

Literature states that about 236 patient identification errors occurred when patients lost bracelet identifiers (Rahmawati et al., 2020). This required a robust identification system for patients, such as biometric systems such as iris biometric systems where iris scanning for each patient is conducted to store as a template. This scanned template matches the patient for routine care treatment deliveries (Anne et al., 2020).

Other strategies include developing and enforcing standardized protocols for patient identification, including using checklists for verification. Implementing these checklists during patient encounters will reduce the incidence of patient misidentification, particularly before administering medications or vaccines (Riplinger et al., 2020). Moreover, healthcare professionals must establish regular communication channels, such as huddles or briefings, to discuss patient identification protocols and address any concerns or challenges the healthcare team faces. Furthermore, healthcare professionals must be trained on the importance of patient identification and ways to mitigate human errors that lead to patient harm (Vaismoradi et al., 2020). By implementing these strategies substantiated by literature and studies, patient identification errors can be effectively reduced, enhancing patient safety and facilitating patient experience.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The safety improvement plan can effectively solve patients’ misidentification and subsequent implications of impaired patient safety. This plan will include implementing enhanced barcoding technology, developing standardized protocols and checklists for patient identification, and training for healthcare staff. The hospital administration will integrate an advanced barcoding system that extends beyond medication administration to include patient identification bracelets. The healthcare facility can ensure robust verification by expanding barcoding technology to patient identification, reducing misidentification risk (Romano et al., 2021).

Healthcare leadership will play a role in developing and enforcing standardized protocols and checklists for patient identification, emphasizing barcode scanning as a crucial step. Combined with checklists, these procedures create a systematic approach to patient identification and reduce the likelihood of errors. Lastly, the plan will include implementing ongoing human factors training for healthcare, where leaders will emphasize the importance of attention to detail in patient identification. Educating staff on common human errors that lead to patient identification errors will empower them with strategies to prevent these errors and enhance the safety culture (Romano et al., 2021). The desired outcomes of this safety improvement plan are reducing patient identification errors, enhancing patient safety, improving patient and family satisfaction, and increasing staff awareness and competence in patient identification.

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

The timeline for the proposed improvement plan will be about one year. In the first two months, the healthcare organization will assess current patient identification processes and areas for improvement. In months 3-4, administrative staff will procure and implement an advanced barcoding system for the identification of patients. This will be followed by developing and disseminating standardized protocols and initiation of training for healthcare staff and administrative personnel in the next two months to promote patient safety through correct patient identification. Lastly, the next four months will include monitoring and evaluating the efficacy of implemented changes and plans as needed based on feedback and outcomes (Vaismoradi et al., 2020).

Existing Organizational Resources

The carefully curated safety improvement plan can be efficiently improved by leveraging the existing organizational resources such as EHR systems. The IT professionals can be approached to assess the lagging features of currently used EHR, which can alarm the healthcare professionals in case of misidentification. Additionally, the administration and leadership team within the hospital can collaborate with Quality Improvement teams to monitor and assess the effectiveness of implemented strategies. The ongoing feedback from the QI team can contribute to continuous improvement in reducing identification errors and enhancing patient safety (Alomari et al., 2020).

Apart from leveraging the currently available resources, the healthcare organization may need additional resources for the training department, such as brochures for educating and consultants to conduct specialized training programs on patient identification and safety concerns. Additionally, healthcare administration will require vendor support for integrating the barcoding system. Financial resources will be needed to purchase and smoothly integrate the technology and training sessions (Riplinger et al., 2020).

Given the central role of technology within the safety improvement plan, collaborating with the IT department is a high priority as it directly impacts the successful implementation of the barcoding system. Other priorities include QI team involvement and training and development resources for ensuring healthcare professionals are adept in patient safety through adequate knowledge of suggested protocols (Alomari et al., 2020).


The root-cause analysis was performed for two patients to address the patient identification errors for children within Arnold Palmer Hospital. The root causes were a lack of protocols for enhanced patient safety and identification of patients, communication breakdowns, inefficient technology, and human error. This required the application of evidence-based practices, utilizing which a safety improvement plan is crafted.

This plan includes integrating a barcoding system, training staff, and enforcing protocols for better patient identification. It is essential to consider the readily available resources that can be strategically used to improve the efficiency of safety improvement plans. The required resources include financial and external resources such as vendors and consultants to implement the proposed plan for enhancing patient safety and reducing identification errors during patient encounters.


Alomari, A., Sheppard‐Law, S., Lewis, J., & Wilson, V. (2020). Effectiveness of clinical nurse’s interventions in reducing medication errors in a pediatric ward. Journal of Clinical Nursing29(17-18), 3403–3413. 

Anne, N., Dunbar, M. D., Abuna, F., Simpson, P., Macharia, P., Betz, B., Cherutich, P., Bukusi, D., & Carey, F. (2020). Feasibility and acceptability of an iris biometric system for unique patient identification in routine HIV services in Kenya. International Journal of Medical Informatics133, 104006. 

Barakat, S., & Franklin, B. D. (2020). An evaluation of the impact of barcode patient and medication scanning on nursing workflow at a UK teaching hospital. Pharmacy8(3), 148. 

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing46(6), 884–891.

Rahmawati, T. W., Sari, D. R., Ratri, D. R., & Hasyim, M. (2020). Patient identification in wards: What influences nurses’ complicance? Jurnal Medicoeticolegal Dan Manajemen Rumah Sakit9(2). 

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient identification techniques – approaches, implications, and findings. Yearbook of Medical Informatics29(1), 81–86.

Romano, R., Marletta, G., Sollami, A., La Sala, R., Sarli, L., Artioli, G., & Nitro, M. (2021). The safety of care focused on patient identity: An observational study. Acta Bio Medica : Atenei Parmensis92(Suppl 2), e2021038. 

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health17(6), 1–15.

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