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Root Cause Analysis and Improvement Plan Discussion

Root Cause Analysis and Improvement Plan Discussion

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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.

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.

 

 

 

Medication Errors

Student’s Name

Institutional Affiliation

 

 

 

 

 

 

 

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 fatigue-outcomes 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

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 nature of care, personal experiences and satisfaction will rise and in the end, healthcare outcomes will rise. 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.

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.

 

 

 

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-die-from-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.

 

 

 

 

 

 

 

 

 

Root-Cause Analysis and Safety Improvement Plan

YOUR NAME

NURS-FPX4020

Capella University

Month, Year

 

 

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 your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:

  • What was supposed to occur?
    • Were there any steps that were not taken or did not happen as intended?
  • What environmental factors (controllable and uncontrollable) had an influence?Root Cause Analysis and Improvement Plan Discussion
  • What equipment or resource factors had an influence?
  • What human errors or factors may have contributed?
  • Which communication factors may have contributed?

These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event.

Application of Evidence-Based Strategies

Identity best practices strategies to address the safety issue or sentinel event.

  • Describe what the literature states about the factors that lead to the safety issue.
    • For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.
    • Explain how the strategies could be addressed in safety issues or sentinel events.Root Cause Analysis and Improvement Plan Discussion

Improvement Plan with Evidence-Based and Best-Practice Strategies

Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain:

  • Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
    • Support these recommendations with references from the literature or professional best practices.
  • A description of the goals or desired outcomes of these actions.
  • A rough timeline of development and implementation for the plan.

Existing Organizational Resources

            Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.

  • A brief note on resources that may need to be obtained for the success of the plan.
  • Consider what existing resources may be leveraged to enhance the improvement plan?Root Cause Analysis and Improvement Plan Discussion

Conclusion

References