Root-Cause Analysis and Safety Improvement Plan

By systematically identifying the cause of near misses and unfavorable events, a root cause analysis helps determine the best course of action for preventative measures (Peerally, et al, 2017). It is now more crucial than ever for nurses to comprehend the context of their roles in administering medication, particularly in light of the nurse's criminal conviction last year for a medication error (Hawkins & Morse, 2022). This paper aims to investigate the underlying causesof medication errors, identify evidence-based practice applications, develop an improvement plan using best practice and evidence-based strategies, and highlight applicable organizational resources.Analysis of the Root CauseAfter receiving care for a brain injury at Vanderbilt Hospital, 75-year-old Charlene Murphey was required to have a PET scan before she could be released. Murphey was prescribedthe common medication Versed, which is used to calm patients experiencing claustrophobia during imaging (Santa Clara University, 2022). Instead of taking versed out of the computerized medicine cabinet, RaDonda Vaught, the patient’s nurse, took out vecuronium, a paralyzing agent.According to an investigation report included in the court case, the nurse took the incorrect medication, injecting Murphey before her scan, and ignored multiple warning indications because versed is a liquid and vecuronium is a powder. Additionally, Vaught failed to follow up with Murphey following her vecuronium administration, which hindered her from realizing her error in time to administer an antidote that might have reversed her paralysis (Santa Clara University, 2022). Vaught also stated that she was training a new nurse the day of the incident,