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

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

Root-Cause Analysis and Safety Improvement Plan

Root Cause Analysis (RCA) is a systematic process to identify the underlying reasons for problems or incidents within systems, processes, or events. This RCA explores medication administration challenges within vulnerable populations, such as the homeless, migrants, and prisoners, within community health centers. Wang et al. (2021) reported that more than half a million people are without homes in the United States. Individuals experiencing homelessness frequently suffer from both acute and chronic illnesses and encounter significant challenges in accessing community healthcare services. This assessment proposes evidence-based strategies to address these issues, aiming to improve medication safety and ultimately enhance health outcomes for vulnerable populations accessing care in community health centers.

Analysis of the Root Cause

Issue Description

The RCA focuses on the challenges encountered in ensuring safe medication administration among vulnerable populations, such as the homeless, migrants, and prisoners.  A homeless individual with diabetes faced challenges accessing and administering insulin, resulting in severe hyperglycemia at a community health center. Staff at the center detected the issue upon the individual’s arrival, and they diagnosed a medication error. This medication administration failure affected both the individual’s health, worsening their condition and strained the center’s resources. It led to increased healthcare interventions and potentially avoidable complications, impacting overall patient care and resource allocation.

Analysis of the Event

Homeless individuals face barriers in accessing consistent healthcare, leading to fragmented care and difficulty in managing medications regularly. According to Rahman et al. (2020), vulnerable populations often have lower health literacy, impacting their understanding of medication instructions and contributing to administration errors or missed doses. Homeless individuals encounter challenges such as a lack of medication storage, clean water access for administration, and refrigeration for medications like insulin, hindering adherence to prescribed regimens. Limited access to healthcare facilities and financial constraints prevent consistent medication acquisition, potentially leading to rationing or sharing of medications and increased risk of errors (Coube et al., 2023). Distrust of healthcare providers and communication barriers delay open dialogue about medication concerns, leading to underreporting of issues and missed intervention opportunities.

Root Cause

The primary root cause identified is the absence of tailored healthcare services and support systems for vulnerable populations, exacerbating disparities in safe medication administration. Additionally, a lack of cultural competence and training among healthcare providers may contribute to errors in medication administration. Healthcare professionals may not be adequately trained to address vulnerable populations’ specific needs and challenges. It will further complicate medication management and potentially lead to adverse outcomes (Coube et al., 2023). Without addressing these deficiencies in cultural competence, training, and social determinants of health, the cycle of poor health outcomes among these groups will persist.

Application of Evidence-Based Strategies

To address the root cause of the lack of safe medication administration within vulnerable populations like the homeless, migrants, and prisoners, it is crucial to apply evidence-based and best-practice strategies. Providing cultural competence training to healthcare staff is crucial. It helps understand the unique backgrounds, beliefs, and preferences of the populations they serve. This approach mitigates communication barriers and enhances trust, reducing the potential for misunderstanding-related medication errors (Alizadeh & Chavan, 2020). The literature emphasizes the importance of clear communication to prevent errors, making cultural competence training a key strategy in addressing the safety issue. 

Developing educational materials and programs empowers patients from vulnerable populations to manage their medications actively. By offering culturally sensitive information about medication use, potential side effects, and the importance of adherence, this strategy directly combats the factors identified in the literature contributing to medication errors (Gartley, 2022). Informed and empowered patients are more likely to follow medication regimens accurately, minimizing safety risks. Fostering collaboration between healthcare providers, social workers, and community organizations addresses the multifaceted needs of vulnerable populations. 

The effective communication strategy goes beyond individual responsibilities, allowing for a comprehensive approach to medication management. Addressing social determinants of health collaboratively mitigates the risk of medication errors associated with systemic issues (Alderwick et al., 2021). In addition, exploring technology solutions like medication reminder apps, telehealth platforms, or Electronic Health Records (EHRs) improves medication adherence and care coordination (Jiron et al., 2023). This also directly addresses interruptions during medication administration by providing reliable reminders and enhancing communication between patients and healthcare providers, reducing the likelihood of errors.

Improvement Plan with Evidence-Based and Best-Practice Strategies

To address medication administration challenges among vulnerable populations like the homeless, migrants, and prisoners, a comprehensive safety improvement plan should be implemented at community health centers. Mandatory cultural competence training programs for all healthcare staff will enhance their ability to deliver patient-centered care to diverse socio-economic backgrounds, reducing barriers to medication administration. Training modules will cover implicit bias awareness, effective communication strategies, and cultural sensitivity in healthcare delivery (Kwame & Petrucka, 2021). Utilizing resources from organizations like the Agency for Healthcare Research and Quality (AHRQ) ensures evidence-based guidelines and training materials ( Agency for Healthcare Research and Quality, 2020). Tailored educational materials and workshops on medication management, adherence, and self-care practices empower individuals to actively participate in their health (Bhattad & Pacifico, 2022). These resources, accessible and culturally appropriate, draw upon research studies and best practices from organizations such as the Centers for Disease Control and Prevention (CDC).

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

Interdisciplinary care teams at community health centers will address social determinants of health, providing holistic care and connecting individuals with resources such as housing assistance and food security programs. Research by Frempong & Tijani (2022) reported that evidence-based models like the Patient-Centered Medical Home (PCMH) framework ensure effective care coordination among vulnerable populations. Implementing technology-driven solutions like EHR systems and telemedicine platforms streamline medication management processes and enhance communication between providers and patients (Ford et al., 2020). Drawing upon studies and guidelines from reputable sources like the Health Information and Management Systems Society (HIMSS) ensures effective utilization of health IT in medication management.

Goals and Timeline

The goals and the desired outcomes of this improvement plan are to enhance cultural competence among healthcare providers and empower patients to manage their medications effectively. The plan also addresses social determinants of health, leveraging technology to improve medication safety and adherence among vulnerable populations. Development of the plan, including cultural competence training and resource gathering, spans 3 months. Implementation, involving staff training and resource dissemination, takes place over 6 months. Continuous evaluation and adjustments occur over the following year to ensure effectiveness and sustainability.

Existing Organizational Resources

Identifying resources within healthcare settings and community centers is critical for enhancing safety plans addressing medication challenges in vulnerable populations. First and foremost, evaluating the current staff composition is paramount. This entails identifying individuals with expertise in critical areas such as cultural competence training, patient education, care coordination, and technology implementation (Turin et al., 2021). By leveraging the skills and knowledge of these healthcare personnel, the plan can benefit from their specialized understanding and experience in tackling the complexities of medication management within vulnerable communities.

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

The internal resources, like training departments within community health centers, present valuable capacity-building opportunities. These departments can facilitate cultural competence training programs, equipping healthcare staff with the necessary skills to engage effectively with diverse patient populations (Cole et al., 2022). Moreover, collaborating with IT departments is essential for exploring and implementing technology solutions tailored to medication management needs. This collaboration ensures that technological interventions align with existing systems and infrastructure, maximizing efficiency and efficacy.

While existing resources provide a solid foundation, they may need to be supplemented with external expertise and resources. For success, community health centers may need external trainers with cultural competence and culturally specific training materials addressing bias, communication strategies, and healthcare aspects for diverse populations (Kerrigan et al., 2020). Moreover, collaborating with reputable technology vendors enables the customization and implementation of technology solutions tailored to the unique needs of community health centers.

Tapping into in-house expertise and available materials is paramount in leveraging existing resources. Healthcare providers and staff with prior experience in addressing challenges faced by vulnerable populations offer valuable insights and perspectives. Utilizing existing training materials and guidelines provided by reputable organizations further enhances the quality and relevance of educational initiatives. Additionally, leveraging established care coordination models like the PCMH allows for adapting proven frameworks to suit the specific needs of vulnerable populations (Mongelli et al., 2020). Encouraging internal collaboration and communication between departments within community health centers ensures a cohesive and integrated approach to the safety improvement plan, maximizing its impact and effectiveness.


The RCA for safe medication administration within vulnerable populations, like the homeless, migrants, and prisoners, underscores the necessity of understanding their unique healthcare challenges. Factors such as discontinuity of care, limited health literacy, practical obstacles, resource constraints, and communication barriers contribute to medication errors. Addressing these issues requires tailored healthcare services, cultural competence training, patient education, interdisciplinary collaboration, and technology solutions. Leveraging existing organizational resources and obtaining external expertise and technology are vital for implementing evidence-based strategies to improve medication safety and healthcare access for vulnerable populations. Successful execution demands a holistic approach, integrating knowledge, resources, and innovation.


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