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Root-Cause Analysis and Improvement Plan
Omolola Roberts
Capella University
NURS-FPX4020: Improving Quality Care Patient Safety
Prof. Fallon Benavides
April, 2024.
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Root-Cause Analysis and Improvement Plan
Root-cause analysis (RCA) is a systematic method used to determine the underlying cause or
causes of an issue or problem. It involves investigating the events and factors that led up to the
problem to identify what went wrong and why. RCA helps in analyzing the root cause of the
problem and avoiding its recurrence in the future (Singh et al, 2021). A root-cause analysis was
conducted in an inpatient health unit to identify the causes of patient identification errors. The
paper describes and analyzes these errors and discusses evidence-based strategies to reduce
them. Furthermore, it determines a safety improvement plan based on the utilization of existing
organizational resources to address these patient identification errors.
Root-Cause Analysis of Patient Identification Errors
Patient identification errors can occur due to human factors, which refer to mistakes made by
healthcare professionals or workers. These mistakes may include misinterpreting handwritten
information, mishearing patient names, and misreading identification wristbands. According to
Sameera et al. (2021), human errors account for a significant proportion of preventable disasters
in healthcare, and even the most competent clinicians are not immune to them. Errors in patient
identification can have serious consequences, and therefore, clinicians must be aware of the
impact of human errors and how to prevent them. Although it is a common saying that "to err is
human," these errors may occur due to long working hours, distractions, and job dissatisfaction.
Patient misidentification is a common issue in hospitals, and one of the main reasons for it is
patient factors. Patients may provide incorrect or outdated information about their identity or
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health status, especially if they are unable to communicate effectively. This can happen due to
unconsciousness, language barriers, or patients unwilling to disclose their true identity.
According to Fukami et al. (2020), discrepancies in patient identification procedures are the most
significant cause of misidentification. Inconsistencies between verbal identification and
wristband or health record details can result in patient identification errors. These errors may
occur due to technical errors or human omission during registration.
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References
Singh G, Patel RH, Boster J. Root Cause Analysis and Medical Error Prevention.(2023). In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available
from: [Link]
Sameera, V., Bindra, A., & Rath, G. P. (2021). Human errors and their prevention in healthcare.
Journal of anaesthesiology, clinical pharmacology, 37(3), 328–335.
[Link]
