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Root-Cause Analysis and Safety Improvement Plan

The safety concern pertaining to medication administration in a healthcare setting, which needs to be addressed, is persistent medication administration errors, which occur through treatment management mistakes. The root cause of this issue is the poorly designed medication administration protocols, and it is also attributable to the failure to observe the right guidelines and policies during treatment administration. The issue of medication administration mistakes has been persistent in the Mayo Clinic healthcare setting, whereby several inaccuracies have been experienced in the recent past. Some of these mistakes involved the administration of the incorrect dose, wrong medication, and missing doses, and which are the universally reported medication administration errors in the healthcare setting (Hammoudi et al., 2018). This paper will discuss the root-cause analysis of the safety issue of medication administration errors, application of evidence-based strategies, safety improvement plan with evidence-based and best-practice strategies, and the existing organizational resources.

Analysis of the Root Cause

The root cause of the persistent medication administration and treatment management errors includes poor communication between the care providers and patients, having drug labels that sound similar and medicine prescriptions that are similar. When administering medication, one can make diverse errors, such as wrong dose prescription, incorrect time, erroneous drug, mistaken means, exclusion of some dosages, mistaken patient, lack of certification, and methodological errors. In the Mayo Clinic setting, there were common medication administration errors, such as improper diagnosis, counseling errors, dose inaccuracies, disastrous drug distribution, observes drug and drug expedient associated problems, improper drug management, unsuccessful communication, and absence of suitable patient education (Hammoudi et al., 2018). This problem was detected by the return clients of the Mayo Clinic healthcare setting, and they raised complaints of the above-mentioned medication administration errors. This issue mainly affected the patients, their families, and the entire community that was receiving healthcare services from the Mayo Clinic (Koyama et al., 2020). The issue had a direct negative impact on the patients and their families due to inaccuracies involving missing medications (oversights), duplicate medications, and dosing errors in drug interactions that even worsened the condition of some patients.

The noteworthy negative effects of the medication administration errors to the patients included deterioration of ailment, insubstantiality, antagonistic medication occurrences, and prolonged stay in the hospital. The issue also triggered the increment of increases in the charges when seeking for further medication to elevate their condition. While the medication administration errors occurred unintentionally, they had a significant impact on the care seekers and providers; a phenomenon that contributed to some cases of hostile mental and adverse expressive effects on the convoluted providers (Koyama et al., 2020). Some of the key side effects of this issue to the patients included occurrences of burnout, lack of attentiveness, underprivileged work enactment, prompting of posttraumatic stress disorder, melancholy, suicidality, and rejection (Thompson et al., 2018). Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. For some patients who were given the wrong route of drugs and inappropriate dosage course, the problem caused serious and longstanding undesirable effects, and also death.

What was supposed to occur was the aggregate adherence to guidelines and offering of dosage prescriptions in the administration of medications. This would have resolved the breaches experienced during the administration of drugs. Considering the cause of this issue, it is evident that there were some steps not taken, and also the administration of the medication to some patients’ care practices was not conducted as intended (Keers et al., 2018). The controllable and uncontrollable environmental factors that had influenced the issue of medication administration errors included extraordinary noise levels that interrupted the communication between the patients and the caregivers, poor lighting and inappropriate environmental temperature, the principles of the operational environment, and the degree of drug faults that resulted in the medication errors (Koyama et al., 2020). The other environmental factors that affected the problem included element contamination, environmental pollution, adverse weather changes, and the presence of some disease-causing microorganisms, the absence of high-quality health care infrastructure, and poor services eminence.

The resource factors that had an influence that had influence in the problem were the Mayo clinic’s health care assets and materials, the facilities, personnel, and funds that were involved in the provision of health care in the amenity. The human errors and factors that contributed to the issue included the patients’ and caregivers’ emotional stress, lack of inspiration, having a huge workload, ordinary deprived communication, and misused patient data stored in the information systems, which acted as the causative to the medication administration errors experienced (Thomas et al., 2017). The communication factors that contributed to the medical administration issue were listening and paying attention to the doctor’s prescriptions, the approach used in the communication, the patient’s emotional awareness, the use of written communication, and communicating in problematic situations.

Application of Evidence-Based Strategies

The previous literature states that the occurrence of medication administration mistakes is characteristically alleged to the failure of the conventional rights of treatment management (Keers et al., 2018). This involves practices such as not treating the right patient, offering the wrong medication, wrong time prescription, and the incorrect dose route. These factors have contributed to the safety issue because they involve the typical processes for ensuring that the healthcare setting achieves safe medication administration (Stricker et al., 2020). The recent literature has accentuated that the errors that occur in medication administration and treatment process are part of the complex medication process, which involves multidisciplinary teams that work together to guarantee patient-centered quality care delivery (Wen et al., 2019). Poor communication and lack of patient education during medication administration increase the risk of medication errors. Strategies can be used to address the medical administration errors safety issue by providing solutions to the existing care gaps, which lead to the occurrence of medical administration mistakes (Stricker et al., 2020). The best practices that can be used to address the issue include introducing standardized communication, providing appropriate patient education, and enhancing nursing workflow to reduce possible errors.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The practices that should be taken by the Mayo Clinic healthcare setting to address the root causes of the medical administration error issue include the arrangements, new processes, the new policies, and/or professional development that will be undertaken to address all the root causes. The implementation of standardized communication in the Mayo Clinic Health System will improve the patient and caregiver communication principles are used to safeguard recommending the right medication (Thompson et al., 2018). Furthermore, ordinary abbreviations and arithmetical conventions are suggested by the shared directives. The management of suitable patient education in the healthcare setting will help to mitigate the risk of healing management errors (Koyama et al., 2020). This will be important for all healthcare providers to utilize the perfect communication approaches and policies routinely provided by the education programs to patients, particularly when prescription procedures are modified and adapted.

There will be new processes in optimizing the nursing workflow meant to reduce the medical administration’s potential errors. In health care settings, distractors during the medication administration process are common and associated with increased risk and severity of errors (Wen et al., 2019). Minimizing interruptions during medication administration and structuring care checks through consistent workflows will be a key strategy in enabling the safe administration of medications. Some policies such as the Medicines Act 1968 will be important in the provision of the main legal frameworks for the medication prescribing, and supplying of the appropriate storage and management of medicines, categorizing them into the right categories (Koyama et al., 2020). This policy will be fundamental because it is the law that covers the administration of medicine among patients. The goals and the described outcomes of the above actions are to improve the status of medication administration, to evade medication errors and interruption, and to prepare the medications for patients at a while to avoid misperception (Hammoudi et al., 2018). This plan will be implemented in the course of four months, and the outcomes will be assessed after every month.

Existing Organizational Resources

The organizational personnel that would help in the improvement of the implementation and the outcomes of the plan includes the Mayo Clinic Healthcare professionals actively convoluted in excellence development exertions, which are nurses, medical technicians, physicians, and other medical provision staff (Stricker et al., 2020).. The organizational resources that may be needed to obtain success for the plan are materials, personnel, funds, and facilities involved in the provision of quality health care services (Thomas et al., 2017). Therefore, the essential resources in this plan will be human recourse (work resources), capital (cost resources), and material goods (material resources).


The occurrence of medication administration errors denotes the inaccuracies inexperienced in the recommending, dispensing, giving, and prescription of medications. In the past, medication administration errors have caused injury and pain to many patients in the U.S. However, utmost of the experienced medication administration errors are prevented. The best practices to thwart medication administration errors involve enhancing patient education and introducing standardized communication in the health care setting. The causative factors for this safety issue are also attributed to caregivers, patients, and practitioner errors related to low healthiness literacy, deprived patient-provider communication, deficiency of health knowledge, and collective precautions in the Mayo Clinic outpatient instances.


Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046.

Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PloS one, 13(10), e0206233.

Koyama, A. K., Maddox, C. S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ quality & safety, 29(7), 595-603.

Stricker, N. H., Lundt, E. S., Alden, E. C., Albertson, S. M., Machulda, M. M., Kremers, W. K., … & Mielke, M. M. (2020). Longitudinal comparison of in clinic and at home administration of the cogstate brief battery and demonstrated practice effects in the Mayo Clinic Study of Aging. The journal of prevention of Alzheimer’s disease, 7(1), 21-28.

Thomas, L., Donohue-Porter, P., & Fishbein, J. S. (2017). Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Journal of Nursing Care Quality, 32(4), 309-317.

Thompson, K. M., Swanson, K. M., Cox, D. L., Kirchner, R. B., Russell, J. J., Wermers, R. A., … & Naessens, J. M. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351.

Wen, A., Fu, S., Moon, S., El Wazir, M., Rosenbaum, A., Kaggal, V. C., … & Fan, J. (2019). Desiderata for delivering NLP to accelerate healthcare AI advancement and a Mayo Clinic NLP-as-a-service implementation. NPJ digital medicine, 2(1), 1-7.


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