Root Cause Analysis and Improvement Plan

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Find attached the “root cause analysis” as a word document needed for this assessment.

Find attached a sample of this assessment as a pdf.

Find attached “assessment 1” which is talked about on the instructions for this assessment.

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. 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 1 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.

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.

Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis Sample Student Work

Root cause analysis is a process through which causes of adverse events and other issues that almost occur are analyzed so that preventive measures or improvements can be made (Spath, 2011). This paper provides and root cause analysis and improvement plan for the patient safety and reduction in falls for geriatric patients in inpatient geriatric units. Moreover, the paper provides evidence-based strategies that aim to improve the safety of the geriatric patients through reduction of falls. The evidence based strategies are used to determine a safety improvement plan depending on existing resources. The RCA is provided for a geriatric unit in a county medical center facility. The geriatric unit for the medical center is made up of a 100 bed ward.

Analysis of the Root Cause: Safety of Geriatric Patents Concerning Falls in Inpatient Geriatric Units

Patient safety entails protection of the patient from issues such as injuries during health care (Cameron et al. 2018). Patient falls are thus ranked amongst the prevalent patient safety issue in hospitals, especially geriatric units. The geriatric unit experiences many falls and is amongst the leading causes of injury deaths in the older patients. With an expected increase in the aging population, it is also likely that the number of elderly patients rises. The patient falls in the geriatric units are often witnessed, and they are referred to medical errors that need to be addressed since is it a safety issue. Such medical errors as falls occur due to issues such as environmental errors, lack of interprofessional teamwork, and ineffective communication between patients and the caregivers (Cameron et al., 2018). The root cause analysis (RCA) is used in the review of falls in a geriatric unit at a medical center.

The RCA is conducted for the geriatric unit that reported 30 falls the previous year and has been averaging over 30 falls annually since 2010. The primary objective of the RCA is to establish what leads to the falls amongst the patients within the unit and provide a possible solution to deal with the falls. The RCA analysis was the role of an interprofessional team, including one supervisor, two nurses, one clinician, and a quality improvement officer. The 30 reported cases are reported by the nurses, and they are often recorded and found in the geriatric unit’s electrical records with 2 of the cases being fatal as it led to the death of the patients due to concussions. Other results of the falls were injuries, including body swellings, fractures, pain, and abrasions. Most of the reported cases were associated with tripping and slipping and mostly in or near the patients’ beds. Moreover, most of the falls were reported during the evenings, early mornings, and at nights when the nurses were understaffed or when there were changing their shifts.

Various factors subject the geriatric patients to falls, for example, being under the influence of medication, for example, antidepressants and most of them also have cognitive psychology issues that make them forget things. As they wander within the units, they are subjected to environmental risk factors that can cause the falls. The use of medicine leads the geriatric patients to lack voluntary muscle control (ataxia), impaired cognitive or motor functions (extrapyramidal slowing), and decrease in blood pressure within few minutes of continuous standing (orthostatic hypertension) (Phelan et al., 2014). These issues subject the patients to risks of falls as they can just collapse or slip. Some of the drugs that have been associated to these falls include sedatives, antipsychotics, antidepressants, hypnotics, non-benzodiazepines, and alpha- blockers (Phelan et al., 2014). According to the experts that reviewed the reported cases at the geriatric unit, about 65% of the falls were associated with patients being under drug influence as the falls took place within ten minutes of the drugs being administered. The other 35% are associated with general body weaknesses in the geriatric patients, cognition impairment, and partial blindness that leads to mobility difficulties, thus the falls. Most of the patients from the reported ones that fell were in treatment for cardiovascular and neurodegenerative related diseases. The geriatric unit environment was also attributed as one of the main factors that lead to falls as the beds are not designed to hold the patients in their beds, the glass doors confuse the elderly patients with most having cognition and visual impairment issues, poor lighting, and the footwear was risky on the tilled floors since liquid leakages are regular in the unit.

Improvement Plan with Evidence-Based and Best-Practice Strategies

According to Spruce (2015), evidence based research in nursing leads to the establishment of the best interventions to improve quality of care. Preventive and improvement strategies are required to help in the reduction of the falls in the geriatric unit. The improvement plan focuses on two aspects, including improving the quality of healthcare services by the staff and the creation of an environment at the geriatric unit with minimal risk factors.

The first part of the plan focuses on quality care to improve the general safety of the patient. Since most of the falls were attributed to the medication issues, patient monitoring needs to be improved to reduce the effects that drugs have on these patients. To aid in this process, several aspects are required including physical therapy and exercise programs, minimizing and withdrawal of psychoactive medications, increasing nurse staffing during night shifts and effective communication amongst staff. Physical therapy or exercise programs must be started on the patients to ensure that there is improvement of strength, balance, and gait (Ambutas et al., 2017). As identified earlier, some of the main issues associated with falls are the general body weaknesses amongst the patients. Therefore, physical therapy would go a long way in improving the general body weakness through improving the body strengths and balance of the patients (Lee et al., 2013). All the patients in the geriatric unit would be required to undergo physical therapy. Another issue in the first part of the plan is to reduce, withdraw, or find alternatives for the psychoactive drugs (Lee et al., 2013). 65% of the falls were attributed to drug influence and thus reducing the use of the identified drugs, withdrawing them all together in situations that they are not required, and finding less influential alternatives can lead to minimizing the falls. Another aspect in this part of the plan is to increase the staff nursing during the night shift to improve the monitoring of these patients as more nurses will be doing rounds in the unit and apart from the video monitoring physical monitoring where the nurses go to the patients’ bed at regular intervals would help in reducing the falls. The nurses would also undergo communication training to improve effective communication between themselves and between them and the patients (Cameron et al., 2018).

The second part of the improvement plan focuses on the geriatric unit environment. One of the main issues proposed is the changes in footwear and management of footwear by the hospital. The experts proposed that patients be provided with footwear that has grip even on the hospital’s slippery tiled floors. Another environmental proposal is the improvement of lighting by ensuring that there are enough light sources both at night and during the day and this ensures that patients can see well and know where there are obstacles (Lee et al., 2013). This aspect will help mainly the patients that have problems with their eyesight due to old age. The glass doors will be replaced with wooden or plastic doors with bright colors, and this will enable the patients to see the doors and avoid collision as one of the issues that cause the falls. Finally, the beds will be fitted with protective boards, and electric alarms that would warn the nurses in case a patient needs anything (Shorr et al., 2012) Training of the staff and patients on the use of the electric alarms would be however essential to ensure that it is effective in reducing the falls.

Existing Organizational Resources

The improvement plan would require the use of existing organizational resources in its implementation process. The plan would require human resources and their skills and expertise, and this would include more nurses being deployed for the night shit hours. The existing staff would be trained on the specific additions such as the provision of physical therapy and the use of electric alarms. The environmental improvement part of the plan would require leveraging the existing capital in the medical center since it requires the installation of additional components such as lighting, buying of footwear, electric alarms, and the replacing of the doors. Mills (2016) states that leveraging of the existing human and capital resources ensure that the medical center would reduce the overall costs. Moreover, leveraging of existing resources ensures that the disruption in service provision within the geriatric unit is minimally affected.

Root Cause Analysis and Improvement Plan References

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.

Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane database of systematic reviews, 9(9), CD005465. https://doi.org/10.1002/14651858.CD005465.pub4

Lee, A., Lee, K. W., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal, 17(4), 37–39. https://doi.org/10.7812/TPP/12-119

Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and management of fall risk in primary care settings. The Medical clinics of North America, 99(2), 281– 293. https://doi.org/10.1016/j.mcna.2014.11.004

Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636–639.

Shorr, R. I., Chandler, A. M., Mion, L. C., Waters, T. M., Liu, M., Daniels, M. J., Kessler, L. A., & Miller, S. T. (2012). Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster-randomized trial. Annals of internal medicine, 157(10), 692–699. https://doi.org/10.7326/0003-4819-157-10-201211200- 00005

Spath, P. L. (2011). Error Reduction in Healthcare: A Systems Approach in Improving Patient Safety (2nd ed.). San Francisco: Jossey-Bass.

Spruce, L. (2015). Back to basics: Implementing evidence-based practice. AORN

Journal: The Official Voice of Perioperative Nursing, 101(1), 106–114.

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Running head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN Root-Cause Analysis and Improvement Plan Learner’s Name Capella University Improving Quality of Care and Patient Safety Root-Cause Analysis and Improvement Plan March, 2019 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 1 ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 2 Root-Cause Analysis and Improvement Plan According to Spath (2011), root-cause analysis is a methodical approach that aims to discover the causes of adverse events and near misses for the purpose of identifying preventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls in geropsychiatric patients was conducted at an inpatient mental health unit. The paper describes and analyzes falls and discusses evidence-based strategies to reduce falls and determine a safety improvement plan based on the utilization of existing organizational resources to address these falls. Root-Cause Analysis of Falls in Geropsychiatric Inpatients According to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control and Prevention reported that falls were a leading cause of unintentional injury death in adults aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead to serious head trauma are common among older adults. Injury falls are serious and could lead to fractures, head injury, and intracranial bleed. According to the National Quality Forum (2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope et al., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate their health conditions (Powell-Cope et al., 2014). Considering the adverse implications of falls in such patients, a root-cause analysis was conducted on the 20 cases of falls reported over a period of one year at a geropsychiatric inpatient facility. The aim of the analysis was to understand the causes of falls in geropsychiatric patients at the unit. The analysis was conducted by a team of five experts including clinicians, supervisors, and quality improvement personnel. The cases reported had been registered by a team of nurses who collated the data related to the falls. All the falls were described as cases of slipping or tripping, and patients mostly sustained injuries involving pain, mild swelling, and abrasions, with only two of the cases involving minor Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 3 fractures. It was also observed that all the falls occurred near the beds of patients and during the evening or night shifts when nursing teams were more likely to be understaffed. Geropsychiatric patients are known to be susceptible to falls under the influence of drugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in blood pressure within three minutes of standing), ataxia (lack of voluntary muscular control caused by injury to the central nervous system), and extrapyramidal slowing (impaired motor functions) due to the use of drugs such as antidepressants, antipsychotics, sedatives, hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to these kinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of falls and noted that in over 50% of the cases, patients had been ambulating under the influence of drugs. It was also noted that 80% of the patients who fell while ambulating under the influence of drugs had been prescribed zolpidem. At least 40% of the falls could be attributed to generalized weakness, disorientation, and difficulty with mobility. Fall and injury risks are often complicated by behavioral circumstances such as anger, anxiety, hyperarousal, and the inability to call for help or to remember to call for help. Root Cause Analysis and Improvement Plan

Physical conditions that occur with substance abuse (such as malnourishment and dehydration) co-exist with psychiatric disability and cause further complications (Powell-Cope et al., 2014). Another factor that plays a role in patient safety is infrastructure in hospitals. This was particularly noteworthy as all the falls studied had occurred when patients ambulated near their beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskid footwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al., 2014). Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 4 Application of Evidence-Based Strategies to Reduce Falls Considering that all the falls reported occurred near the patients’ beds, infrastructural changes such as the installation of bed- and chair-exit alarms are recommended. Falls from beds are common in patients with cognitive impairments. Installing electronic alarm systems was found to be a feasible and effective fall prevention strategy in such cases (Wong Shee, Phillips, Hill, & Dodd, 2014). Strategies such as team engagement and proactive planning to avoid falls can be implemented in inpatient geropsychiatric wards. Forming a quality and patient safety team can serve as an essential safety net and drive a proactive approach rather than a reactive one toward reducing sentinel events. Such a team could include existing staff in the unit that are selected based on their skills and experience. The primary focus of the team would be to identify, evaluate, measure, and improve processes and activities related to patient safety within the unit (Serino, 2015). Better management of medication must be implemented to reduce falls that occur under the influence of drugs. Administering melatonin instead of zolpidem reduces the level of sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroom at night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014). Improvement Plan The improvement plan involves a two-pronged approach: improving staff effectiveness and coordination and implementing environmental modifications. The first part of the plan focuses on increasing the effectiveness of patient monitoring and staff coordination through intentional rounding, one-to-one observation of patients, and increased communication among staff. Intentional rounding is a system wherein the nursing staff conduct structured routine checks on patients at regular intervals. The duration of intervals is decided based on the needs of patients in the unit. Intentional rounding is known to be Copyright ©2019 Capella University. Root Cause Analysis and Improvement Plan

Copy and distribution of this document are prohibited. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 5 particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation is recommended for high-fall-risk patients. One-to-one observation of patients by moving them close to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinel events can be prevented by promoting interdisciplinary collaboration in health care. Good communication and collaboration between physicians, therapists, kinesio therapists, and occupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014). The second part of the improvement plan focuses on environmental modifications to existing infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alert staff when a patient attempts to leave the chair or bed has proven to be effective in reducing falls. These alarms can be attached to the patient directly or to the chair or bed the patient uses (Wong Shee et al., 2014). Other recommended environmental modifications include using creative display signage beside patients’ beds. This could be magnets next to the name of a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Such displays alert staff and visitors of the risk involved with each patient. The use of nonslip strips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitary ware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patient safety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained to facilitate and monitor the use of environmental modifications such as electronic alarms to ensure their successful implementation. It is crucial to identify and leverage existing organizational resources when implementing the improvement plan. The first part of the improvement plan involves utilizing the skills and expertise of existing staff members rather than hiring new members to assist in fall prevention. To improve monitoring of patients, the staff members are trained on intentional rounding techniques and one-to-one observation. The environmental interventions suggested in the second part of the plan involve the installation of additional components to Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 6 existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existing resources reduces the overall cost and effort involved in implementing the plan and ensures minimal disruption to ongoing patient routines and staff-led fall-prevention practices within the unit. Conclusion Falls are the leading cause of unintentional injury deaths in geropsychiatric patients and are largely preventable. A root-cause analysis of falls in such patients was conducted at an inpatient mental health unit. Infrastructural gaps and ambulation under the influence of drugs were found to be primary factors that precipitated the falls reported in the unit. The paper discusses evidence-based strategies such as medication management, installation of electronic alarms, and formation of a quality and patient safety team that would help reduce falls. A two-pronged improvement plan was formed to systematically reduce falls in the unit. The plan involved improving staff effectiveness and coordination and implementing environmental modifications. Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. Root Cause Analysis and Improvement Plan

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 7 References Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10. http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8 Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff‐led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1-2), 115–124. http://dx.doi.org/10.1111/jocn.13401 Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., … Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339. https://doi.org/10.1177/1078390314553269 Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN Journal, 102(6), 617–628. https://doiorg.library.capella.edu/10.1016/j.aorn.2015.10.006 Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. Running Head: MEDICATION ERRORS Medication Errors Student’s Name Institutional Affiliation 1 MEDICATION ERRORS 2 Factors Leading to Medication Errors Medication errors are quite common in the US health care industry. In a certain study, it was established that 64.55% of nurses had made medication errors while 31.37% of nurses assert that they were on the verge of making medication errors. It has also been established that up to 98,000 patients die from medication errors in the US every year (Allen, 2013). Several factors are attributed to the presence of medication errors. Kohn, Corrigan, & Donaldson (2000) explain that suboptimal conditions under which nurses work are linked to the high number of medication errors. Moreover, the lack of adequate staff and the shortage of physicians are other leading causes of medication errors. The argument here is that the poor working conditions and lack of adequate staff trigger physiological stress and fatigueoutcomes that in the end induce burnout. The resulting burnout makes it impossible for nurses to work efficiently, implying that the likelihood of a medication error to occur increases significantly. The lack of patient involvement has similarly been cited as a leading cause of medication errors. The rationale is that the absence of more patient involvement makes it impossible to identify harmful events that can cause medication errors. Also, the lack of vigorous follow-ups can trigger medication errors. Kohn, Corrigan, & Donaldson (2000) have described several latent factors that trigger medication errors. To begin with, the authors claim that insufficient training on new members has been described as a leading cause of medication errors. Insufficient training reduces accuracy and efficiency, factors that influence the occurrence of medication errors. Again, the inability to properly set up infusion devices allows for the possibility of an error to emerge. Kohn, Corrigan, & Donaldson (2000) add that scheduling problems deny nurses sufficient time to properly set up devices. Evidence-Based and Best-Practice Solutions MEDICATION ERRORS An array of solutions has been proposed to reduce medication errors. One, Kohn, Corrigan, & Donaldson (2000) argue that the devices should be redesigned to make them safer to use. Additionally, effort should be made to reduce the complexities involved in using multiple devices. Furthermore, new staff should be sufficiently trained on standard practices and the use of devices (Kohn, Corrigan, & Donaldson, 2000). The idea is to enhance the competency level of everyone. It is also extremely important to provide a supportive environment that would prevent burnout. The healthcare entities should hire more nurses and reduce working hours to minimize fatigue. Again, healthcare organizations should minimize the variety of devices purchased to ensure that everyone can competently utilize the devices (Kohn, Corrigan, & Donaldson, 2000). When nurses have to use a variety of devices, they need more training and technical guidance, a scenario that creates room for error to emerge. When the frequency of medication errors is reduced, the related costs will also be reduced as hospitals will compensate fewer people while also limiting the costly follow-up activities. How Nurses can Help Coordinate Care Nurses can help coordinate care to increase patient safety with medication administration and reduce costs in several ways. One, they can coordinate care by creating a holistic approach that will replace the disease-based approach that is common in healthcare settings. The holistic approach will give patients more input in the management of diseases while improving communication across care settings. When patients influence the natur e of care, personal experiences and satisfaction will rise and in the end, healthcare outcomes will rise. Root Cause Analysis and Improvement Plan

Again, the improved communication will streamline information flow and ease decision making, factors that can improve the quality of healthcare provided. Furthermore, given that nurses engage with patients at a deeper level, they can coordinate care by designing effective care plans. These plans can improve the quality of care; enhance care outcomes as well as wellbeing. 3 MEDICATION ERRORS Moreover, nurses help coordinate care as they facilitate the continuity of care by connecting patients to appropriate care units and specialists. Also, nurses help coordinate care as they educate patients and their families at discharge. The information and support nurses provide in this respect are crucial in that it prevents the breakdown of care outside of healthcare organizations. Stakeholders Several stakeholders can help nurses coordinate to drive safety enhancements with medication administration. The patients are part of the stakeholder system because they receive care. When patients are more involved in care activities, it becomes easier for the nurses to offer fully patient-centered care. Secondly, the Center for Patient safety is the second stakeholder that can help drive safety enhancements with medication administration (Kohn, Corrigan, & Donaldson, 2000). This organization is crucial as it will expand the knowledge base on safety and while also connecting healthcare organizations with the right tools out of which meaningful progress can be made. The Agency for Healthcare Research and Quality (AHRQ) can also help drive the culture of safety as it is involved in addressing quality issues, quality improvement and the identification of best practices (Kohn, Corrigan, & Donaldson, 2000). In other words, AHRQ is involved in the creation of solutions that can help address medication errors. The National Patient Safety Foundation (NPSF) can also be quite helpful as it raises awareness, fosters communication, establish collaborative relationships and design educational programs that enhance patient safety (Usher et al., 2017). For instance, the educational programs offered by NPSF can enhance the competency to administer drugs and use medical devices, factors that can help address the related latent causes. 4 MEDICATION ERRORS 5 References Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-diefrom-medical-mistakes-in-u-s-hospitals. Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research, 18(3), 228–231. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Usher, K., Woods, C., Parmenter, G., Hutchinson, M., Mannix, J., Power, T., … & Jackson, D. (2017). Self-reported confidence in patient safety knowledge among Australian undergraduate nursing students: A multi-site cross-sectional survey study. International Journal of Nursing Studies, 71, 89-96. Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis and Safety Improvement Plan YOUR NAME NURS-FPX4020 Capella University Month, Year 1 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings. Analysis of the Root Cause Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as: • What happened? • Who detected the problem/event? • Who did the problem/event affect? • How did it affect them? Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting y …Root Cause Analysis and Improvement Plan