NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan Sample

Healthcare institutions have a well-defined process for conducting a systematic analysis of problems. The root-cause analysis is one of the most commonly used tools in this process. Root-cause analysis, as defined by Singh et al. (2021), refers to tools, approaches, and techniques used to identify the source of a problem. The root-cause analysis allows healthcare institutions to optimize care and design interventions to reduce negative outcomes in care. A root-cause analysis established to uncover the causes of medication prescription errors (MPEs), as discussed further below, is an example in health. In the discussion, a well-executed safety improvement plan to minimize adverse outcomes is also included. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis

The identification of a multidisciplinary team to identify the problem is the first step in root cause analysis. In this case, the issue is MPEs, and the team consists of the prescriber, nurses, pharmacists, and, to a lesser extent, patients. The stratification of the causes into people, environment, methods, and systems or policies will be invaluable for the ease of identification of the causes of the problem. For example, under people, MPEs have been attributed to doctors’ poor penmanship. Because doctors are required to perform a variety of activities related to patient care, they are frequently pressed for time and, as a result, scribble down orders that are prone to errors in dosages, frequencies, or routes (Tariq et al., 2021 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan). Under environmental factors, distractions, as evidenced in practice and literature, are the most common cause and attribute to 75% of MPEs (Tariq et al., 2021). Distractions can come from fellow medics, patients, or anyone else in the ward’s vicinity. Patients crying out for help, moving along the corridors to the washrooms, colleagues consulting and asking questions, and subordinate staff cleaning the wards and corridors are all distractions that can divert the prescriber’s attention.

Under methods, abbreviations of medical terminologies are frequently used. However, drugs with similar generic names may have the same abbreviations, resulting in incorrect interpretation by pharmacists and the dispensing of incorrect medications (Tariq et al., 2021). Furthermore, apothecary or metric measures are commonly used during prescriptions. Incorrect use of these measures, such as not writing a zero before a decimal point (Insulin .5 IU/kg) instead of Insulin 0.5 IU/kg, can lead to medication errors. Concerning the system or policies, a suboptimal medication error reporting system can lead to MPE underreporting (Tariq et al., 2021 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan). A non-functional Medication error reporting system is common in hospitals with poor collaboration of care providers, low motivation, and an increased work burden.

Evidence-Based Best Practices to address MPEs

Several evidence-based strategies for reducing the occurrence of MPEs have been proposed. In my institution, an emphasis has been placed on the medication error reporting system, and as a result, there is a welcoming environment in which open communication among care providers is encouraged. According to the literature, the majority of MPEs, such as incorrect dosage and infusion rate, are reported through an effective reporting system (Rodziewicz et al., 2021). Most institutions also encourage doctors to write orders or prescribe medications only at specific times, usually after the ward rounds, when there are fewer distractions and the likelihood of MPEs is lower.

Furthermore, educating prescribers on prudent prescribing is an evidence-based method of mitigating MPEs. This education can be provided through seminars, online webinars, and regular workshops, with one example being the antibiotic stewardship program, a coordinated initiative to promote the appropriate use of antimicrobials (Nimarko et al., 2020 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan). Some organizations use prescription tools such as the STOPP (Screening Tool of Older Persons’ Prescriptions) and the START (Screening Tool to Alert to Right Treatment) to minimize MPEs. Moreover, MPEs can be greatly reduced by consulting before writing orders and double-checking dosages, frequencies, and routes.

Viable Evidence-Based Safety Improvement Plan for Safe Medication Administration

In healthcare, technology has been greatly leveraged to improve care outcomes. In an effort to reduce MPEs, electronic health records are being used to replace handwritten prescriptions. Wang et al. (2019) reported that using a computerized prescription tool eliminated MPEs caused by doctors’ poor penmanship. Furthermore, the computerized prescription tools automatically calculate dosages, standardize medication dosages, and sequence treatment days (Wang et al., 2019). The computerized prescription systems include embedded alert systems that detect any errors in the prescriptions

A computerized physician order entry system was successfully implemented in a Latin American hospital’s outpatient chemotherapy clinic. According to the findings of Valencia et al. (2018), the system successfully standardized 266 chemotherapy orders, and software that was linked to laboratory results allowed entry of important patient information such as anthropometric information for a fully automated dose calculation. As a result, such a system has been shown to be effective in lowering MPEs and improving patient safety.

Existing Organizational Resources that can enhance Patient Safety

As previously stated, my institution takes pride in having an effective medication error reporting system that improves detection of any MPEs. Having such an effective system in place is a top priority and a sufficient organizational resource that can improve patient safety. It is thus the responsibility of each health institution to motivate its employees, provide a safe work environment, and increase their satisfaction in order for them to be willing to promote the medication error reporting program. Furthermore, health institutions in the United States, for example, access the Pharmacopeia list of medications that are similar or have similar generic names and are likely to be confused (Tariq et al., 2021). As a result, the United States Pharmacopeia is a resource that health institutions can use to prevent medication errors. Furthermore, the Institute of Safe Medication Practices maintains a list of all abbreviations that are frequently misinterpreted, as well as the names of high-risk medications (Tariq et al., 2021 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan). Every time a doctor writes a prescription, he or she can refer to the lists to ensure that the correct orders and prescriptions are written.

Conclusion

Through safe evidence-based practices, MPEs are preventable actions. However, before implementing safe preventative measures, it is recommended that a root-cause analysis of the problem be performed. As can be seen, the causes of MPEs are numerous, with distractions being the most common. This therefore necessitates strategies. To reduce distractions while writing order. Technology has also provided a promising first step towards lowering MPEs. However, implementation has been difficult because most hospitals do not yet have an electronic medical record or any other systems or software that can incorporate computerized prescription. As technology advances, there is still hope that handwritten prescriptions will become obsolete in the near future.

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan References

Nimarko, K., Bandali, A., Bias, T. E., & Mindel, S. (2020). Impact of an antimicrobial stewardship team on reducing antiretroviral medication errors. The Annals of Pharmacotherapy, 54(8), 767–774. https://doi.org/10.1177/1060028019900677

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Singh, G., Patel, R. H., & Boster, J. (2021). Root cause analysis and medical error prevention. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570638/

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and prevention. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Valencia, F. S., Ruiz, R., Neciosup, S. P., Mas, L. A., Aliaga, K. M., Huaman, F., Ruiz, J., Vasquez, E., Llacctahuaman, N., Pedraza, R., Paz, M., Aguirre, W., & Gomez, H. L. (2018). Implementation of computerized physician order entry for chemotherapy: A Latin American experience. JCO Clinical Cancer Informatics, 2(2), 1–12. https://doi.org/10.1200/CCI.18.00041

Wang, J., Liang, H., Kang, H., & Gong, Y. (2019). Understanding health information technology induced medication safety events by two conceptual frameworks. Applied Clinical Informatics, 10(1), 158–167. https://doi.org/10.1055/s-0039-1678693

Assessment 2 Instructions – NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

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 – NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

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.

Please utilize the template

Use the Root-Cause Analysis and Improvement Plan [DOCX] template 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 – NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

  • 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.
  • SCORING GUIDE
  • Root-Cause Analysis and Safety Improvement Plan Scoring Guide

Grading Rubric

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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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.

Evidence-Based Practice Resources

    • Abstract: Evidence-based practice (EBP) competencies represent essential components of nursing education at all levels. The transition of EBP learning goals from the baccalaureate to the Master of Science in nursing and Doctor of Nursing Practice levels provides a blueprint for the development and advancement of student knowledge, skills, and attitudes. The purpose of this article is to describe 3 nursing curricula related to EBP competencies at the baccalaureate, master’s, and Doctor of Nursing Practice levels (Hande, Williams, Robbins, & Christenbery, 2017).
  • Sukkarieh-Haraty, O., & Hoffart, N. (2017). Integrating evidence-based practice into a Lebanese nursing baccalaureate program: Challenges and successes. International Journal of Nursing Education Scholarship14(1), 441–442.
    • Abstract: Evidence-based practice (EBP) is defined as “the conscientious use of current best evidence in making clinical decisions about patient care.” This paper describes how we have developed the evidence-based practice concept and integrated it into two courses at two different levels of the BSN curriculum. Students apply EBP knowledge and process by using the PICO clinical question (Population, Intervention, Comparison and Outcome), whereby they observe a selected clinical skill, and then compare their observations to hospital protocol and against the latest evidence-based practice guidelines. The assignment for the second course requires students to pick a more complex clinical skill and to support proposed changes in practice with scholarly literature. Assessment of student learning and course evaluation has shown that the overall experience of integrating EBP projects into the curriculum is fruitful for students, clinical agencies, and faculty (Sukkarieh-Haraty & Hoffart, 2017 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan).
  • Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, barriers and potential strength of nursing in implementing evidence-based practice. International Journal of Caring Sciences13(2), 1203–1211.
    • This article provides methods for identifying the readiness, barriers, and potential strengths of implementing evidence-based practice.
  • Lee, S. K. (2016). Implementing evidence-based practices improves neonatal outcomes. Evidence-Based Medicine21(6), 231.
    • This journal article provides a framework for identifying and appraising research, as well as implementing change and practices based on research.

Quality and Safety

    • 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
  • The Joint Commission. (2018). 2018 national patient safety goals. 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 programAORN Journal103(6), 636–639. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
    • Explore numerous resources related to quality and safety on this website as you develop your assessment submission. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis

  • Institute for Healthcare Improvement. (n.d.). Cause and effect diagram [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/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. http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
    • Abstract: An estimated 250,000 deaths occur annually are attributed to preventable medical errors. Approximately 100,000 of those deaths are related to miscommunication between healthcare providers. Miscommunication between healthcare providers during the transfer of care accounts for 80% of sentinel events occurring in the hospital setting. The hand-off communication continues to be one of the primary causes of sentinel events in healthcare in spite of the continued research focus over the past 10 years. The transfer of care communication between providers is called the “hand-off,” “change of shift report,” or “handover.” The hand-off for purposes of this study is defined as the process of transferring patient care, responsibility, and authority from one nurse to another at the change of shift. Specifically, we are concerned about the communication of clinical events (CE) experienced by the patient because CEs are precursors to a sentinel event. A CE is defined as a change in the patient’s condition in the following areas: bleeding, pain, fever, and changes in output, respiratory status, or level of consciousness (Galatzan, 2019 NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan). NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
  • Minnesota Department of Health. (n.d.). Root cause analysis toolkit. https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/
    • The Minnesota Department of Health offers an extensive collection of resources related to root-cause analysis. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
  • The Joint Commission. (n.d.). Framework for conducting a root cause analysis and action plan. 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

    • 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. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Safety and Sentinel Event Case Studies

  • Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
  • Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

See NURS-FPX4020 Assessment 3 Here.