The third strategy is to implement an automated error reporting system that includes a patient-specific automated medication system (npsAMS) unit, barcode medication administration (BCMA), and a complex automated medication system (cAMS) with the automated dispensing unit to reduce human errors in communication and decision-making. As the process used an integrated system, the errors were reduced from 0.96 to 0.15 (Risør et al., 2018). Koyama et al. (2021) proposed an EBP strategy to double-check medicine through the checklist, implementing hierarchical protocols, and educating interprofessional teams to reduce medication administration errors. The strategy reduced errors as double-checking reduced human errors. Also, recommendations by QSEN and IOM to train health care staff to communicate and collaborate aid in both error prevention and management (Abukhader & Abukhader, 2020).

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

Improvement Plan with Evidence-Based and Best-Practice Strategies

The action plan is multi-disciplinary and multimodal as it includes different actions for different stakeholders. The first step is to develop a hospital-based protocol and hierarchical response system with a medication error alert system to quickly detect the errors and provide steps taken to report the error along with the responsibilities of different stakeholders (Huckels-Baumgart et al., 2017). This plan aid in solving the first root-cause where the pharmacist sent the wrong product. The outcome of this step is it increases knowledge and competencies along with better communication between the team (Korb-Savoldelli et al., 2018).