NSG/468: Influencing Quality Within Healthcare Wk 4 – Multifactorial Medication Mishap RCA

Read the Multifactorial Medication Mishap case study (Used with permission: Agency for Healthcare Research and Quality Patient Safety Network).

Complete the Root Cause Analysis Worksheet to analyze the case.

Multifactorial Medication Mishap Case Study:

The Case A previously healthy 50-year-old man was hospitalized while recovering from an uncomplicated spine surgery. Although he remained in moderate pain, clinicians planned to transition him from intravenous to oral opioids prior to discharge. The patient experienced nausea with pills but told the bedside nurse he had taken liquid opioids in the past without difficulty. The nurse informed the physician that the patient was having significant pain and liquid opioids had been effective in the past. When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system, multiple options appeared on the list — two formulations for tablets and two for liquid (the standard 5 mg per 5 mL concentration and a more concentrated 20 mg per mL formulation).

At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry with a brand name. In all, the physician saw eight different choices for oxycodone products. The physician chose the concentrated oxycodone liquid product and ordered a 5-mg dose. All medication orders at the hospital had to be verified by a pharmacist. The pharmacist reviewing this order recognized that the higher concentration was atypical for inpatients but assumed it was chosen to limit the volume of fluid given to the patient. The pharmacist verified the order and, to minimize the risk of error, added a comment to both the electronic medication administration record (eMAR) and the patient-specific label that the volume to be given was 0.25 mL (5 mg). For added safety, the pharmacist personally retrieved, labeled, and delivered the drug and a calibrated syringe to the bedside nurse to clarify that this was a high concentration formulation for which the volume to administer was 0.25 mL (a smaller volume than would typically be delivered).

Shortly thereafter, the nurse went to the bedside to administer the drug to the patient for his ongoing pain. She gave the patient 2.5 mL (50 mg) of liquid oxycodone, a volume that she was more used to giving, and then left for her break. A covering nurse checked on the patient and found him unconscious — a code blue was called. The patient was given naloxone (an agent that reverses the effect of opioids), and he responded well. He was transferred to the intensive care unit for ongoing monitoring and a continuous infusion of naloxone to block the effect of the oxycodone. By the following morning, the patient had returned to his baseline with no apparent adverse effects.

Write a 525 word-summary in which you:

  • Explain why a root cause analysis was appropriate for this situation.
  • Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.

Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.

University of Phoenix Material


Medication Mishap Root Cause Analysis Worksheet


Complete the table below to analyze the Week 4 case study. The analysis questions in the table have been adapted from The Joint Commission’s Root Cause Analysis and Action Plan Framework you reviewed in this week’s learning activity.



Analysis Questions Considerations Root Cause Analysis Findings Root Cause(Y/N)
What was the intended process flow? List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event.    
Were there any steps in the process that did not occur as intended? Explain in detail any deviation from the intended processes.    
What human factors were relevant to the outcome? Staff-related human performance factors such as fatigue, distraction, etc.    
How did the equipment performance affect the outcome? Consider all medical equipment and devices.    
What controllable environmental factors directly affected this outcome? Consider things such as overhead paging that cannot be heard or safety or security risks.    
What uncontrollable external factors influenced this outcome? Factors the organization cannot change    
Were there any other factors that directly influenced this outcome? Internal factors    
What are the other areas in the organization where this could happen? List where the potential exists for similar circumstances.    
Was the staff properly qualified and currently competent for their responsibilities at the time of the event? Evaluate processes in place to ensure staff is competent and qualified. N/A N/A
How did actual staffing compare with ideal levels? Include ideal staffing ratios and actual staffing ratios along with unit census. N/A N/A
What is the plan for dealing with staffing contingencies? What the organization does during a staffing crisis N/A N/A
Were such contingencies a factor in this event? If alternative staff used, verify competency and environmental familiarity. N/A N/A
Did staff performance during the event meet expectations? To what extent did staff perform as expected within or outside of the processes?    
To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? Patient assessments were complete, shared and accessed by members of the treatment team    
To what degree was the communication among participants adequate for this situation? Analysis of factors related to team communication and communication methods    
Was this the appropriate physical environment for the processes being carried out for this situation? Proactively manage the patient care environment.    
What systems are in place to identify environmental risks? Were environmental risk assessments in place?    
What emergency and failure-mode responses have been planned and tested? What safety evaluations and drills have been conducted?    
How does the organization’s culture support risk reduction? Does the overall culture encourage change, suggestions, and warnings from staff regarding risky situations or problematic areas? N/A N/A
What are the barriers to communication of potential risk factors? Describe specific barriers to effective communication among caregivers.    
How is the prevention of adverse outcomes communicated as a high priority? Describe the organization’s adverse outcome procedures. N/A N/A
How can orientation and in-service training be revised to reduce the risk of such events in the future? Describe how orientation and ongoing education needs of the staff are evaluated.    
Was available technology used as intended? Such as: CT scanning equipment, electronic charting, medication delivery system, tele-radiology services    
How might technology be introduced or redesigned to reduce risk in the future? Describe any future plans for implementation or redesign.    

Week 4: Medication Mishap RCA


Content: 180 points possible Points possible Points earned Comments
Completed the RCA worksheet accurately and in an appropriate level of detail 80    
Explained why a root cause analysis was appropriate for this situation 40    
Analyzed the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care 40    


Format: 20 points possible Points possible Points earned Comments
Followed a structure that is clear, concise, and appropriate; maintains a scholarly tone 10    
Cited a minimum of two peer reviewed or evidence-based sources published within the last five years to support the summary 10  


Points earned/possible




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