Root-cause analysis of a quality or safety issue in a health care setting

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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 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]

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?
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.

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?

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].

Running head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 1

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

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

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. 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).

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

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

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.root-cause analysis of a quality or safety issue in a health care setting

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.

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.13401root-cause analysis of a quality or safety issue in a health care setting

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://doi- org.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

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.

SCORING GUIDE

Root-Cause Analysis and Safety Improvement Plan Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Does not identify the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Does not describe evidence-based and best-practice strategies pertaining to medication administration.	Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Applies evidence-based 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.
Create a viable, evidence-based safety improvement plan for safe medication administration.	Does not create a viable, evidence-based safety improvement plan for safe medication administration.	Creates a safety improvement plan for safe medication administration that lacks appropriate, convincing evidence of its viability.	Creates a viable, evidence-based safety improvement plan for safe medication administration.	Creates a viable, evidence-based safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for safe medication administration are unclear.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration, prioritizing them according to potential impact.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Does not organize content for ideas. Lacks logical flow and smooth transitions.	Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling.	Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.	Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.	Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.