Systems Analysis


When an adverse event, such as erroneous medication administration, occurs, a review of the system is conducted using analysis tools such as a root cause analysis (RCA). The goal of such review processes is to adopt measures that will prevent such events in the future. Medical errors often involve more than one individual. Therefore, a systems approach is required to analyze and understand the processes and structures in the system that caused the adverse outcome. Such an approach will also help plan strategies that prevent the reoccurrence of such events. To also proactively address quality issues, organizations participate in strategic planning. A SWOT analysis is a proactive quality improvement tool that will assist in collecting information about an organization’s strengths, weaknesses, opportunities, and threats. As a nurse leader, your understanding of SWOT allows you to actively contribute to establishing initiatives for the organization.


The medication delivery system at a healthcare facility only allows documentation of the medication after it has been administered to the patient. A patient received two doses of a medication. This error was discovered when the second staff nurse came back to chart the dose given and saw that another nurse had charted. You will be conducting a root cause analysis to respond to and investigate this adverse incident. The RCA will help you identify any system errors with medication administration. To prevent such errors in the future, the senior leadership in the healthcare facility wants to take proactive measures. This involves an additional step in the administration process. You have been asked to begin a SWOT analysis to evaluate this additional step. You will analyze if the organization can sustain an additional process in the medication delivery system.


In this activity, you will analyze this incident using RCA and SWOT. You may choose to use PowerPoint or Word for creating the RCA fishbone and SWOT graphics. These will be included in your analysis. You will also write your observations about the tools and the analyses. Provide specific evidence from at least two scholarly sources to support your claims.

Specifically, you must address the following rubric criteria:

  1. Perform a root cause analysis. Complete a root cause analysis to investigate the adverse incident. Explain the system elements and the investigation taking place. Include the following details:
  2. Perform a SWOT analysis. Complete a SWOT analysis and explain the process. Include the following details:
  3. Determine the appropriate application for the tools. Each tool has its own purpose for analyzing systems. Explain when it is most appropriate to use an RCA and a SWOT.
  4. Analyze the output. Describe the expected output from RCA and SWOT.

What to Submit

Submit your analysis as a 2- to 4-page Word document including graphics, using double spacing, 12-point Times New Roman font, and one-inch margins. Sources should be cited according to APA style.

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