Root Cause Analysis of Medical Errors

Evidence-Based Practice • • Giomuso, C. B., Jones, L. M., Long, D., Chandler, T., Kresevic, D., Pulphus, D., & Williams, T. (2014). A successful approach to implementing evidence-based practice. Med-Surg Matters, 23(4), 4–9. • This article provides a baseline definition of evidence-based practice as well as examples of implementing EBP in practice. Spruce, L. (2015). Back to basics: Implementing evidence-based practice. AORN Journal: The Official Voice of Perioperative Nursing, 101(1), 106–114. • This article provides a framework for identifying and appraising research, as well as implementing changes and practices based on research. Quality and Safety • • • • • Ambutas, S., Lamb, K. V., & Quigley, P. (2017). Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units. Medsurg Nursing, 26(3), 175–179, 197. • The implementation of a safety improvement project is examined in this article. Institute for Healthcare Improvement. (n.d.). Why is reducing harm – not just error – important to patient safety? [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/B ates-Reducing-Harm-Important-To-Patient-Safety.aspx • Based on the premise that human error may be reduced but not avoided in every health care situation, this video focuses on the importance of harm reduction to patient safety. Joint Commission. (2018). 2018 national patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx • The patient safety resources on this Web page may be helpful as you develop the improvement plan section of your assessment. Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636–639. • This article summarizes the creation of a safety program to reduce sentinel events. U.S. Department of Health & Human Services. (n.d.). Retrieved from https://www.hhs.gov/ • Explore numerous resources related to quality and safety on this website as you develop your assessment submission. Root-Cause Analysis • • • • • Institute for Healthcare Improvement. (n.d.). Cause and effect diagram [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVi deo/Whiteboard16.aspx • Cause and effect (or fishbone) diagrams are often used in root-cause analyses; this video shows how to create them. Institute for Healthcare Improvement. (n.d.). Introduction to trigger tools for identifying adverse events. Retrieved from http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyi ngAEs.aspx • Tools to identify adverse events and determine their causes are provided on this resource page. Mellinger, E. (2014). Action needed to prevent wrong-site surgery events. AORN Journal, 99(5), C5–C6. • This article examines the role nurses play in preventing and examining sentinel events. Minnesota Department of Health. (n.d.). Root cause analysis toolkit. Retrieved from https://www.health.state.mn.us/facilities/patientsafety/adverseevents/tool kit/ • The Minnesota Department of Health offers an extensive collection of resources related to root-cause analysis. The Joint Commission. (n.d.). Framework for conducting a root cause analysis and action plan. Retrieved from http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_ Analysis_and_Action_Plan/ • With resources for conducting a root-cause analysis and creating an action plan to address the results, this Web page will help you understand the steps and processes of RCAs and improvement plans for this assessment. Sentinel Events • • The Joint Commission. (2017). Sentinel event policy and procedures. Retrieved from https://jointcommission.org/sentinel_event_policy_and_procedures • This Web page provides definitions, policies, and procedures related to sentinel events that may help you complete your assessment. The Joint Commission. (2017). The essential role of leadership in developing a safety culture [PDF]. Sentinel Event Alert, 57, 1–8. Retrieved from https://www.jointcommission.org/sea_issue_57/ • According to The Joint Commission, “Competent and thoughtful leaders…understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.” This issue of Sentinel Event Alert discusses ways that effective leaders foster the development of a safety culture. Safety and Sentinel Event Case Studies • • Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ).;Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/A HRQCaseStudyOneDoseFiftyPills.aspx Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/ WhatHappenedtoJosieKing.aspx Capella Writing Center • Introduction to the Writing Center. • Access the various resources in the Capella Writing Center to help you better understand and improve your writing. APA Style and Format • Capella University follows the style and formatting guidelines in the Publication Manual of the American Psychological Association, known informally as the APA manual. Refer to the Writing Center’s APA Module for tips on proper use of APA style and format. Capella University Library • BSN Program Library Research Guide. • The library research guide will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments. For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue. As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. Root Cause Analysis of Medical Errors

The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes. As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: • • • Competency 1: Analyze the elements of a successful quality improvement initiative. • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ; • Create a viable, evidence-based safety improvement plan for safe medication administration. Competency 2: Analyze factors that lead to patient safety risks. • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. Competency 3: Identify organizational interventions to promote patient safety. Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. • • Professional Context Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements. Scenario For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan: • • The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns. The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration. Root Cause Analysis of Medical Errors

Instructions The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan. Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process. Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand ;what is needed for a distinguished score. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration. • Create a feasible, evidence-based safety improvement plan for safe medication administration. • Identify organizational resources that could be leveraged to improve your plan for safe medication administration. • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration. • Assessment 2 ;Example [PDF]. • Additional Requirements Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4-6 page root cause analysis and safety improvement plan pertaining to medication administration. • Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old. • APA formatting: Format references and citations according to current APA style. Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course. • CRITERIA Analyze the root cause of a patient safety issue or a specific sentinel NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D Does not identify the root cause of a patient safety issue or a specific sentinel event Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication CRITERIA NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D event pertaining to medication administratio n in an organization. pertaining to medication administratio n in an organization. medication administratio n in an organization. medication administratio n in an organization. administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration . Apply evidencebased and best-practice strategies to address the safety issue or sentinel event pertaining to medication administratio n. Does not describe evidencebased and best-practice strategies pertaining to medication administratio n. Root Cause Analysis of Medical Errors

Describes evidencebased and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administratio n is unclear. Applies evidencebased and best-practice strategies to address the safety issue or sentinel event pertaining to medication administratio n. Applies evidencebased and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration , detailing how the strategies will address the safety issue or sentinel event pertaining to medication administration . CRITERIA NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D Create a viable, evidencebased safety improvement plan for safe medication administratio n. Does not create a viable, evidencebased safety improvement plan for safe medication administratio n. Creates a safety improvement plan for safe medication administratio n that lacks appropriate, convincing evidence of its viability. Creates a viable, evidencebased safety improvement plan for safe medication administratio n. Creates a viable, evidencebased safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan. Identify existing organization al resources that could be leveraged to improve a safety improvement plan for safe medication administratio n. Does not identify existing organizationa l resources that could be leveraged to improve a safety improvement plan for safe medication administratio n. Identifies existing organizationa l resources, but their relevance and usefulness to quality and safety improvement for safe medication administratio n are unclear. Identifies existing organizationa l resources that could be leveraged to improve a safety improvement plan for safe medication administratio n. Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration , prioritizing them according to potential impact. Communicat e safety improvement plan using Does not communicate safety improvement plan using Communicat es safety improvement plan using writing that is Communicat es safety improvement plan using writing that is Communicate s safety improvement plan using writing that is CRITERIA writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

NONPERFORMANC E writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. BASIC unclear, illogical, and/or contains numerous errors in grammar or APA style. PROFICIENT clear, logical, and professional, with correct grammar and spelling, using current APA style. DISTINGUISHE D clear, logical, and professional, with correct grammar and spelling, using current, error-free APA style. … Root Cause Analysis of Medical Errors