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

ByDaniel Rossi Updated on

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

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

Patient falls are a global healthcare problem that contributes to poor patient outcomes, increased hospital stays, and increased admission rates. According to Keuseman and Miller (2020), an estimated 40% of all hospital accidents are attributed to patient falls.

Furthermore, it is the second most common cause of prolonged hospital stay after adverse drug events and contributes to increased hospital expenditure, therefore becoming a healthcare burden. Consequently, it is prudent for healthcare set-ups to develop evidence-based interventions to reduce falls and limit their adverse effects. Fortunately, root cause analysis (RCA) offers an opportunity to address healthcare issues and come find solutions.

According to Paulsen. (2021), RCA is an evidenced-based tool that uses a systematic approach of incorporating principles, procedures, and methodologies to identify the root cause of the problem and look for solutions to prevent such errors from occurring in the future. While assessing the cause, RCA tries to identify the risks, the steps missed, what could have been done differently, and why the incident occurred.

Therefore, RCA helps optimize care and improve patient outcomes when used in healthcare. Regarding patient falls, this paper will discuss the root cause analysis, evidenced-based practices, safety improvement plans, and existing organizational resources to prevent falls and improve patient safety.

Analysis of the Root Cause

Root cause analysis uses a systematic approach. The initial step of RCA is problem identification and multidisciplinary team members are concerned with the problem. Patient falls are a healthcare concern with several contributions classified as internal or external causes.

Interna causes are those related to patient factors. Such include increasing age above 65 years, visual impairment, urinary incontinence, dizziness, delirium, certain medications, and previous history of falls. According to Keuseman and Miller (2020), fall risks increase in elderly patients taking medications such as benzodiazepines, psychotropics, and sedatives. These medications cause drowsiness, agitation, confusion, and anxiety, which increases the risk of falls in elderly patients who are essentially unstable or have gait disturbances.

Conversely, extrinsic factors are related to the environmental risks that cause falls. They include poor lighting systems, overcrowding, slippery floors, negligence by healthcare providers, absence of cradles, poor communication, nursing shortage, lack of fall response system, and lack of support from relatives. Furthermore, LeLaurin and Shorr (2019) argue that despite bedside bells being useful in preventing falls, they may contribute to falls.

They state that inappropriate use of bells could lead to agitation, anxiety, confusion, and an increased risk of falls. Therefore, patients and relatives must be educated before using it; otherwise, serious falls may be reported. Nonetheless, the failure of healthcare providers to identify at-risk populations also increases the risk of falls among hospitalized patients. Consequently, patient falls negatively affect patient outcomes.

For instance, patient falls contribute to fractures, dislocation, a complication of other chronic conditions, and other injuries. Therefore, it leads to increased hospitalization, which leads to increased hospital expenditures. Furthermore, patient satisfaction is compromised, making them seek legal options for compensation in case of negligence. Therefore, it is prudent to implementation of interventions aimed at reducing falls.

Application of Evidence-Based Strategies to Prevent Patient Falls.

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

Several levels of evidence-based practice have been deployed in various set-ups to prevent patient falls. One of the most common causes of patient falls is due to negligence. Therefore, my institution has been at the forefront of offering education to healthcare providers about their roles and how they can prevent falls.

The education aims at enlightening caregivers about the risks, prevention strategies, and complications of falls. The use of a risk assessment tool for all patients is the easiest and safest way of classifying patients (Stoeckle et al., 2019). For those at high risk, extra activities are performed. These include hourly rounding, close monitoring, placing them in safe beds, offering bracelets, and training caregivers. Furthermore, prompt medication analysis should be done to eliminate sedative medications from high-risk patients.

Moreover, other interventions applicable to reducing falls involve addressing environmental factors. Such include improving lighting, avoiding slippery floors, addressing nursing shortages, improving communication strategies, and implementing protocols for fall prevention.

According to Francis-Coad et al. (2020), an increasing number of healthcare providers will reduce workload and burnout, thus improving the patient environment while eliminating risks and leading to increased patient safety. Furthermore, patients should be educated about the importance of effective communication with healthcare providers and relatives before leaving their beds.

Improvement Plan with Evidence-Based and Best Practice Strategies

Incorporation of the patient safety improvement corps (PSIC) is the safest method that has been used in various healthcare settings to reduce patient falls. PSIC is a nationwide program in the US for training healthcare providers in safety techniques (LeLaurin & Shorr, 2019). It aims at improving the knowledge and skills of healthcare providers about their safety and that of their patients. Regarding patient falls, PSIC encourages the use of risk assessment tools and post-fall assessment tools. The goal of PSIC is to ensure a reduction in falls in a specific setup and initiate mass education of all healthcare providers about safety techniques.

The risk assessment tools have several questions that help screen all patients as they are admitted. This ensures that high-risk patients are identified while safety steps are implanted to reduce falls. On the other hand, the post-fall assessment tool helps identify both intrinsic and extrinsic factors that may have contributed to falls (Francis-Coad et al., 2020).

Once identified, safety measures are put in place to address the risks to prevent future occurrences of falls. Therefore, all healthcare providers should be equipped with PSIC training to improve patient safety NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan..

Existing organization Resources to Prevent Patient Falls

Falls prevention is a significant healthcare issue requiring various stakeholders’ input while incorporating various resources. As stated earlier, the PSIC program aims at offering training to improve safety. However, there is a need for team members to implement PSIC training to enhance safety NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.

Therefore, all healthcare providers, including nurses, doctors, therapists, and pharmacists, among others, should be included in the training. After acquiring skills, these members can then train others, including security personnel, patients, and relatives, about safe practices to prevent patient falls (Stoeckle et al., 2019). Finally, resources, including brochures, cards, and papers containing safety measures, can be distributed to patients, insurance companies, relatives, and other healthcare providers to improve knowledge.

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

Despite patient falls being a healthcare problem resulting in adverse patient outcomes, root causes analysis offers a systematic approach to reducing falls. RCA identifies the cause of a problem and comes up with a solution to prevent future occurrences. NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.

Known causes of patient falls include impaired vision, negligence by nurses, sedating medications, gait disturbances, slippery floors, and poor lighting. Therefore, RCA helps investigate the root cause deeply and find solutions. The commonly applied solutions to prevent falls are educating healthcare providers about safety techniques and improving the working environment.

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

Francis-Coad, J., Hill, A.-M., Jacques, A., Chandler, A. M., Richey, P. A., Mion, L. C., & Shorr, R. I. (2020). Association between characteristics of injurious falls and fall preventive interventions in acute medical and surgical units. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 75(10), e152–e158. https://doi.org/10.1093/gerona/glaa032

Keuseman, R., & Miller, D. (2020). A hospitalist’s role in preventing patient falls. Hospital Practice (1995), 48(sup1), 63–67. https://doi.org/10.1080/21548331.2020.1724473

LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

Paulsen, M. (2021). Root cause analysis. JAMA: The Journal of the American Medical Association, 325(3), 225–226. https://doi.org/10.1001/jama.2020.24911

Stoeckle, A., Iseler, J. I., Havey, R., & Aebersold, C. (2019). Catching quality before it falls: Preventing falls and injuries in the adult emergency department. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 45(3), 257–264. https://doi.org/10.1016/j.jen.2018.08.001

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

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

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.
    • Create a feasible, evidence-based safety improvement plan.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify existing organizational resources that could be leveraged to improve a plan.
  • 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.
  • The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.
  • One of the case studies from the previous assessment.
  • A personal practice experience in which a sentinel event occurred.

NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan 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 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 in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
  • Create a feasible, evidence-based safety improvement plan.
  • Identify organizational resources that could be leveraged to improve your plan.
  • 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:

  • Assessment 2 Example [PDF].

Also Read:

NURSFPX4020 Capella University Safety Improvement Plan Analysis Paper

NURS-FPX4020 Assessment 2 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. A title page is not required but you must include a reference list as per the template.
  • 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.

Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information.

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.

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

Root cause analysis.

Root-cause analysis is used to point out the causes of adverse occurrences or explore options to prevent them from happening again. The root-cause analysis focused on medication errors and was performed in a nursing home facility following death of a resident patient due to wrongful discontinuation of the medication. This paper explores medication errors and looks at evidence-based and best practices methods to reduce medication errors. Further, the paper suggests a safety improvement plan with a basis on the use of available resources to address the problem.

Analysis of the Problem

The root-cause, in this case, was instigated by the untimely death of an 80-year-old at a nursing home. Angie broke her right; she was taken to the hospital and, after an ORIF was done, transferred back to the nursing home. Angie had been given new medications and ordered to continue taken her previous prescriptions as she had a known history of congestive failure that had lately presented with frequent exacerbations.

Having two medication administration forms in her file contributed to the error. The nurse administering the drug was also distracted by a phone call, signaled a colleague who unintentionally interpreted the indication of Lasix on the new MAR as duplication, and yellowed it out. The medication continued without administration of Lasix.

Consequently, presumed to have been discontinued, Lasix was removed from the cart and sent back to the pharmacy. Days later, Angie’s condition worsened, and resuscitation efforts proved futile. She went into a cardiac arrest and passed on. The sudden death of a patient who had recently responded to treatment affected the nurse in charge, who sought to probe the matter. The event also affected all the nurses at the home, the administration, and the physician who attended to Angie at the hospital.

The medication process has standard laid out procedures. In Angie’s case, the attending nurse should have pursued the yellowing of Lasix to ascertain the reason. The attending should not have removed the old Medication Administration Record from the patient’s file. Maintaining the said record in the patient’s file would have allowed drug reconfirmation when during the next round of administration. Given the history of Congestive Cardiac failure, the discontinuation of Lasix should have raised eyebrows, prompting further investigation into the reason behind such a decision.

Noteworthy is that the environmental factors that contributed to the sad occurrence were controllable. The distraction brought about by the phone call was too huge and the epicenter of the mistake. All stakeholders should have harmonized administration of medication. The communication was appropriate all through save for handing the file midway when picking the call. Therefore, the root causes for the grievous error were modifiable environmental distractions, failure to adhere to standard administration protocols, and modifiable environmental factors.

Application of Evidence-Based Strategies

All nurses are vulnerable to committing medication errors. Workplace interruptions tend to increase the risk for medication errors, with Johnson et al. (2017) reporting that up to 99% of medication preparation or administration are interrupted. In this case, the interruption was the phone call, which caused the attending nurse to lose focus on patient needs and medications. A chaotic work environment can be detrimental to the results of nursing care. According to Johnson et al. (2017), the cost of medication errors remains high, and include lengthened hospital stay, lifetime physical injuries, increased cost of care, and in some cases, death of the patient.

For this reason, there is need for healthcare institutions to effectively leverage existing human resources to ensure full employer participation in improvement activities, staff training and promotion of smooth communication between the different stakeholders. Such initiatives can make it easier for facilities to handle challenges and barriers in patient care. Further, administrators should highlight the importance of complete and comprehensive patient documentation to minimize errors of omission.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan for sustained patient within the facility will focus on three pertinent facets, namely improved communication between nurses and other stakeholders, enhanced collaboration, and elimination of detractors from the work environment, such as cell phones. The first step of this improvement plan entails improving communication between stakeholders to enhance awareness during the provision of care. Collaborative working ensures that nurses and physicians can verify patient information prior to making any changes pertaining to patient care. Further, the plan suggests team empowerment, especially with respect to policy execution, for better patient management (Zamboni, et al., 2020).

Environmental adjustment by creating a telephone station to leave one’s contacts during the administration of medication is equally essential. Nurses should be advised not to use individual cell phones during shifts to minimize cases of distractions. With effective implementation, this plan can help improve the quality of services offered, in addition to minimizing the chances of human errors within the facility. The plan is time-bound, and analysis of progress should commence in two months to review its success or the need for adjustments.

Existing organization resources

It is paramount to identify and apply the available resources appropriately. The facility has enough resources that when employed efficiently, can result in a safe nursing home environment. Foremost, the facility has enough, well-trained nurses to handle the residents of the home. By efficiently applying their skills, knowledge and workplace exposure, the nurses are in a better position to provide safe care (Franks, 2020).

Secondly, the facility has schedules for physician visits every week to ensure that patients receive the intended medical care. Finally, the facility’s human resource management team must ensure that nurses handle patients with minimum interruptions by creating well-defined schedules. Additionally, the management should make it a routine for the head nurse to check and approve all transfers and medication changes for patients within two hours of such change.

Conclusion

Arguably, medication errors are the leading cause of injury, death and increased healthcare costs within nursing homes. The root cause analysis of the causative factors explored in this paper reveal the causes and potential solutions to the issue of medication errors in nursing homes. As observed in the case discussed, nurse distraction occasioned by cell phone use during work hours resulted in the death of a patient, an occurrence that should not happen. This paper has reviewed in-depth evidence-based strategies needed to effectively address the problem, particularly by focusing on human and environment factors that tend to jeopardize service delivery.

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

  • Franks, A. (2020). Use of Simulations to Improve Clinical Judgment in New Graduate Nurses. Walden University.
  • Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett-Jones, T., Weidemann, G., Aguilar, V., & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7), 498-507. doi:10.1111/jonm.12486
  • Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2021). Medication dispensing errors and Prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/
  • Zamboni, K., Baker, U., Tyagi, M., Schellenberg, J., Hill, Z., & Hanson, C. (2020). How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implementation Science: IS, 15(1), 27. https://doi.org/10.1186/s13012-020-0978-z

NURS-FPX4020 Assessment 2 Resources:

Evidence-Based Practice
  • Giomuso, C. B., Jones, L. M., Long, D., Chandler, T., Kresevic, D., Pulphus, D., & Williams, T. (2014).A successful approach to implementing evidence-based practice. Med-Surg Matters, 23(4), 4–9.
    • This article provides a baseline definition ofevidence-based practice as well as examples of implementing EBP in practice.
  • Spruce, L. (2015).Back to basics: Implementing evidence-based practice. AORN Journal: The Official Voice of Perioperative Nursing, 101(1), 106–114.
    • This article provides a framework for identifying and appraising research, as well as implementing changes and practices based on research.
Quality and Safety
Root-Cause Analysis
Sentinel Events
  • The Joint Commission. (2017). Sentinel event policy and procedures. Retrieved from https://jointcommission.org/sentinel_event_policy_and_procedures
    • This Web page provides definitions, policies, and procedures related to sentinel events that may help you complete your assessment.
  • The Joint Commission. (2017). The essential role of leadership in developing a safety culture [PDF]. Sentinel Event Alert, 57, 1–8. Retrieved from https://www.jointcommission.org/sea_issue_57/
    • According to The Joint Commission, “Competent and thoughtful leaders…understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.” This issue of Sentinel Event Alert discusses ways that effective leaders foster the development of a safety culture.
Safety and Sentinel Event Case Studies

Capella Writing Center

  • Introduction to the Writing Center.
    • Access the various resources in the Capella Writing Center to help you better understand and improve your writing.

APA Style and Format

  • Capella University follows the style and formatting guidelines in the Publication Manual of the American Psychological Association, known informally as the APA manual. Refer to the Writing Center’s APA Module for tips on proper use of APA style and format.

Capella University Library

  • BSN Program Library Research Guide.
    • The library research guide will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments.

NURS-FPX4020 Assessment 3 Improvement Plan

!!!Please click the link above for video instructions!!!

For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.

As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.

The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).

As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.

Instructions

The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your presentation 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.

  • List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
  • Explain the need for and process to improve safety outcomes related to medication administration.
  • Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
  • Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
  • Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

There are various ways to structure an in-service session; below is just one example:

  • Part 1: Agenda and Outcomes.
    • Explain to your audience what they are going to learn or do, and what they are expected to take away.
  • Part 2: Safety Improvement Plan.
    • Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
    • Explain why it is important for the organization to address the current situation.
  • Part 3: Audience’s Role and Importance.
    • Discuss how the staff audience will be expected to help implement and drive the improvement plan.
    • Explain why they are critical to the success of the improvement plan focusing on medication administration.
    • Describe how their work could benefit from embracing their role in the plan.
  • Part 4: New Process and Skills Practice.
    • Explain new processes or skills.
    • Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
    • In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
  • Part 5: Soliciting Feedback.
    • Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
    • Explain how you might integrate this feedback for future improvements.

Remember to account for activity and discussion time.

Additional Requirements

  • Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be 10–15 slides.
  • Speaker notes: Speaker notes should reflect what you would actually say if you were delivering the presentation to an audience. Another presenter would be able to use the presentation by following the speaker notes.
  • APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
  • Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.

NURS-FPX4020 Assessment 4: Improvement Plan Tool Kit

For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.

Communication in the health care environment consists of an information-sharing experience whether through oral or written messages (Chard & Makary, 2015). As health care organizations and nurses strive to create a culture of safety and quality care, the importance of interprofessional collaboration, the development of tool kits, and the use of wikis become more relevant and vital. In addition to the dissemination of information and evidence-based findings and the development of tool kits, continuous support for and availability of such resources are critical.

Among the most popular methods to promote ongoing dialogue and information sharing are blogs, wikis, websites, and social media. Nurses know how to support people in time of need or crisis and how to support one another in the workplace; wikis in particular enable nurses to continue that support beyond the work environment. Here they can be free to share their unique perspectives, educate others, and promote health care wellness at local and global levels (Kaminski, 2016).

You are encouraged to complete the Determining the Relevance and Usefulness of Resources activity prior to developing the repository. This activity will help you determine which resources or research will be most relevant to address a particular need. This may be useful as you consider how to explain the purpose and relevance of the resources you are assembling for your tool kit. The activity is for your own practice and self-assessment, and demonstrates 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.
    • Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the value of resources to reduce patient safety risk or improve quality with medication administration.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Present reasons and relevant situations for resource tool kit to be used by its target audience.
    • Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting.

References

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329–342.

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

Professional Context

Nurses are often asked to implement processes, concepts, or practices—sometimes with little preparatory communication or education. One way to encourage sustainability of quality and process improvements is to assemble an accessible, user-friendly tool kit for knowledge and process documentation. Creating a resource repository or tool kit is also an excellent way to follow up an educational or in-service session, as it can help to reinforce attendees’ new knowledge as well as the understanding of its value. By practicing creating a simple online tool kit, you can develop valuable technology skills to improve your competence and efficacy. This technology is easy to use, and resources are available to guide you.

Scenario

For this assessment, consider taking one of these two approaches:

  1. Build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan pertaining to medication administration and put the plan into action.
  2. Locate a safety improvement plan (your current organization, the Institution for Healthcare Improvement, or a publicly available safety improvement initiative) pertaining to medication administration and create an online tool kit or resource repository that will help an audience understand the research behind the safety improvement plan and how to put the plan into action.

Preparation

Google Sites is recommended for this assessment; the tools are free to use and should offer you a blend of flexibility and simplicity as you create your online tool kit. Please note that this requires a Google account; use your Gmail or GoogleDocs login, or create an account following the directions under the “Create Account” menu.

Refer to the following links to help you get started with Google Sites:

  • G Suite Learning Center. (n.d.). Get started with Sites. https://gsuite.google.com/learning-center/products/sites/get-started/#!/
  • Google. (n.d.). Sites. https://sites.google.com
  • Google. (n.d.). Sites help. https://support.google.com/sites/?hl=en#topic=

Instructions

Using Google Sites, assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed.

It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues.

Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include the following:

  • An APA-formatted citation of the resource with a working link.
  • A description of the information, skills, or tools provided by the resource.
  • A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration.
  • A description of how nurses can use this resource and when its use may be appropriate.

Remember that you must make your site ‘public’ so that your faculty can access it. Check out the Google Sites resources for more information.

Here is an example entry:

  • Merret, A., Thomas, P., Stephens, A., Moghabghab, R., & Gruneir, M. (2011). A collaborative approach to fall prevention. Canadian Nurse, 107(8), 24–29.
    • This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting.

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.

  • Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration.
  • Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on medication administration.
  • Analyze the value of resources to reduce patient safety risk related to medication administration.
  • Present reasons and relevant situations for use of resource tool kit by its target audience.
  • Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting.

Example Assessment: You may use the following example 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 tool kit will focus on promoting safety with medication administration. Note that you do not have to submit your bibliography in addition to the Google Site; the example bibliography is merely for your reference.

  • Assessment 4 Example [PDF].

To submit your online tool kit assessment, paste the link to your Google Site in the assessment submission box.

Example Google Site: You may use the example Google Site, Resources for Improved Heparin Infusion Safety, to give you an idea of what a Proficient or higher rating on the scoring guide would look like for this assessment but keep in mind that your tool kit will focus on promoting safety with medication administration.

Note: If you experience technical or other challenges in completing this assessment, please contact your faculty member.

Additional Requirements

  • APA formatting: References and citations are formatted according to current APA style

Annotated Bibliography – Improvement Plan Tool Kit Example

Medication errors in nursing and medical practice are varied and multifactorial. In the in-service seminary presentation, using bedside shift reporting was identified as the best quality improvement toolkit for preventing or reducing the risk of future medication errors from etiologies such as poor documentation and communication.

Various literature items are summarized to enhance a better understanding of the usefulness of bedside shift reporting in promoting patient safety and, thus, good nursing quality. The main themes are addressed: implementing bedside shift reporting, benefits and outcomes of bedside shift reporting, and challenges of bedside shift reporting.

Dorvil, B. (2018). The secrets to successful nurse bedside shift report implementation and sustainability. Nursing Management, 49(6), 20–25. https://doi.org/10.1097/01.numa.0000533770.12758.44

Dorvil did an expert review on the secrets of successful bedside shift reporting nurses. The author of this expert review, Boryana Dorvil, is a DNP and registered nurse who works at the Robert Wood Johnson University Hospital as a case manager, emphasized that implementing bedside shift reporting has to be systemic and planned properly. She explains the benefits that both nurses and patients derive from bedside shift reporting (BSR).

The outstanding advantages are the nurse’s satisfaction, patient satisfaction, and safety. Dorvil also provides a strategic review of the best ways to implement bedside shift reporting in settings where this new toolkit is yet to be installed. The author explained that organization planning and readiness are crucial to implementing bedside shift reporting.

Nursing leadership and consistency in practice make the implementation of BSR successful and habitable. However, cost implications to the organization must be incurred to compensate nurses for their overtime duties. This article benefits a care setting that wants to transition to BSR from the traditional systems.

White-Trevino, K., & Dearmon, V. (2018). Transitioning nurse handoff to the bedside: Engaging staff and patients. Nursing Administration Quarterly, 42(3), 261–268. https://doi.org/10.1097/NAQ.0000000000000298

White-Trevino and Dearmon are nursing care professionals at West Florida Hospital. They aimed at demonstrating how to implement bedside shift reporting in an acute care setting. In the acute care setting, excellent and timely communication is vital to patient safety. Poor communication can lead to medical and medication errors.

This article is useful because it reported findings from a study done after implementing BSR in the emergency room. Before implementing BSR, nurses need to ensure quality and reliable informational exchange in patient care. This information exchange needs to be standardized and patient-centered for a successful handover. This study showed that nurses’ subjective ability to respond timely to patient needs was improved.

By meeting patient needs promptly, their safety risks regarding physical harm will likely reduce. The nurses also derive personal satisfaction with this kind of care. The effectiveness of the reporting process contributes greatly to the reduction in patient risk of harm. Therefore, the methodology used by these authors can be an effective quality improvement progress that would improve our patient safety.

Jimmerson, J., Wright, P., Cowan, P. A., King-Jones, T., Beverly, C. J., & Curran, G. (2021). Bedside shift report: Nurses’ opinions based on their experiences. Nursing Open, 8(3), 1393–1405. https://doi.org/10.1002/nop2.755

Jimmerson and colleagues published a qualitative study about nurses’ experiences on bedside shift reporting. This study acknowledged reduced postimplementation adoption rates of bedside reports. Therefore, they aim to conduct this study to assess the expectedness of nurses and their supervisors on the bedside shift reporting process and postimplementation challenges. This piece of literature gives us the challenges that can anticipate after the implementation of BSR in our setting. This article also gives a nurse the impressions and opinions of other nurses that hwho have implemented this safety strategyfying the original BSR to meet organizational settings and expectations is necessary.

Ernst, K. M., McComb, S. A., & Ley, C. (2018). Nurse-to-nurse shift handoffs on medical-surgical units: A process within the flow of nursing care. Journal of Clinical Nursing, 27(5–6), e1189–e1201. https://doi.org/10.1111/jocn.14254

This article addresses three main themes of using BSR to promote patient safety and improve quality in medical and surgical nursing settings. The effectiveness of a handoff strategy is reflected in the nurse’s performance and patient outcomes. Sometimes, when implementing the BSR, undesired outcomes may be encountered. This article suggests that the handoff strategy adopted must incorporate teamwork and ensure a shared understanding of the patient. When using this resource, the nurse must have their set goals after implementation and evaluate the effectiveness.

Forde, M. F., Coffey, A., & Hegarty, J. (2020). Bedside handover at the change of nursing shift: A mixed-methods study. Journal of Clinical Nursing, 29(19–20), 3731–3742. https://doi.org/10.1111/jocn.15403

This article describes the composition and process of BSR. BSR is risk-laden and time-consuming. However, the composition is basic and roles are defined. The off-going nurse predominates the communication exchange and sharing in the unmodified models. This article is useful for a nurse because it provided insights intothprocessesss and major steps to ensure timeliness in care. The roles of the off-going nurse are essential in communication success.

The degree of patient participation is influenced mainly by the off-going nurse. This resource is a useful reminder to nurses that shift reporting is rich in information sharing and their role at the end of the shift is to connect the patient, their families, and the next care provider. In so doing, their safety of omission of communication or committing miscommunication is reduced.

Bressan, V., Cadorin, L., Pellegrinet, D., Bulfone, G., Stevanin, S., & Palese, A. (2019). Bedside shift handover implementation quantitative evidence: Findings from a scoping review. Journal of Nursing Management, 27(4), 815–832. https://doi.org/10.1111/jonm.12746

This resource addresses the various themes, including BSR frameworks and issues at the transitioning from traditional to BSR systems. Adopting theorganizational change theorye is useful in guiding the transition from the traditional system to the BSR. Therefore, the nurse has to set goals for patient care, nursing care, and organizational management efficiency. While implementing this quality improvement strategy, nurses should aim at reducing caadverse carevents and improve their surveillance. This surveillance may include looking out for potential medication errors at shift handover.

Jakobsson, S., Ringström, G., Andersson, E., Eliasson, B., Johannsson, G., Simrén, M., & Jakobsson Ung, E. (2020). Patient safety before and after implementing person-centered inpatient care – A quasi-experimental study. Journal of Clinical Nursing, 29(3–4), 602–612. https://doi.org/10.1111/jocn.15120

This resource emphasized the need to center care around the patient’s bedside. This improves communication and documentation. According to Jakobsson et al., the centering of care on the patient requires using a standard tool specific to the various patient care settings.

This article can help the nurse to structure the care and understand the vital requirements at shift handover as opposed to the traditional methods where the written handover notes are submitted to the oncoming nurse in the absence of the patient without considering the patient currepatient’sssment at handover. A nurse might consider implementing the findings of this study to improve patient safety through structured documentation.

Patton, L. J., Tidwell, J. D., Falder-Saeed, K. L., Young, V. B., Lewis, B. D., & Binder, J. F. (2017). Ensuring safe transfer of pediatric patients: A quality improvement project to standardize handoff communication. Journal of Pediatric Nursing, 34, 44–52. https://doi.org/10.1016/j.pedn.2017.01.004

This article explained the research evidence associating bedside nursing handoff with reducing medication errors. Reducing medication errors, as aforementioned, improves patient safety and care quality. However, Patton and colleagues insisted that this handoff tool should be systemwide to ensure uniformity and seamless patient care.

Their framework included an emphasis on the need for collaboration between the bedside nursing staff and other care providers. This resource is useful when forming working partnerships in patient care at the bedside. Nurses attempting to implement this resource’s findings must ensure that the process involves stakeholders such as the patient’s family and physicians. This would ensure patient-centered and collaborative care.

Wray, C. M., Arora, V. M., Hedeker, D., & Meltzer, D. O. (2018). Assessing the implementation of a bedside service handoff on an academic hospitalist service. Healthcare (Amsterdam, Netherlands), 6(2), 117–121. https://doi.org/10.1016/j.hjdsi.2017.06.002

The nursing process includes monitoring the outcomes of every intervention in care. This resource presents the need to assess the outcomes of the implementation of bedside service handoff. This article brings out the essence of time and efficiency. Despite consuming a lot of time to implement the BSR, the completeness and efficiencies in the transition were appreciated.

This resource is a reminder that implementing the BSR will take a relatively long time, but the benefits in care efficiency will be seen. Care efficiency is one of the dimensions of quality in healthcare. Efficiencies in medication administration would be improved with efficient documentation and handover. Efficient and safe care is the desire for the role group to meet our patients’ needs.

Wollenhaup, C. A., Stevenson, E. L., Thompson, J., Gordon, H. A., & Nunn, G. (2017). Implementation of a modified bedside handoff for a postpartum unit. The Journal of Nursing Administration, 47(6), 320–326. https://doi.org/10.1097/NNA.0000000000000487

This evidence resource presents a modified version of the BSR. In this article, bedside shift reporting has been modified to meet the various needs of nurses and patients in care collaboration. Some aspects of the shift reporting are done in the nursing station, while the other aspects are completed at the bedside. Therefore, it is a mixed model.

This article is useful to nurses in situations where the complete transition to BSR is difficult for various reasons, such as staff shortage, among other issues. Sometimes, it might be difficult to follow all the medications of the patient accurately during the entire hospital stay. The patient care and medications list may be summarized at the station before proceeding to the bedside to present the patient to the oncoming nurse.

Anthony, M. K., Kloos, J., Beam, P., & Vidal, K. (2018). Innovative approach to reconstruct bedside handoff: Using simple rules of complexity science to promote partnership with patients. Journal of Nursing Care Quality, 33(2), 128–134. https://doi.org/10.1097/NCQ.0000000000000280

Using shift reporting to mitigate the link between safety and quality of nursing care has been described in various literature items. This resource goes the extra mile to describe various innovative concepts that modify bedside shift reporting by making patient-centered rather than nurse-centered approaches. In the nurse-centered approach, the nurse dominates the discussion at shift handoff.

However, in the new handoff model, the nurse does less reporting activities about the patient and instead, the patient reports their situation. This resource is useful in the setting of roles in the team during handoff time. The recommendations can be applied by nurses to prevent medication errors by engaging patients during medication crosschecking.

Patel, S. J., & Landrigan, C. P. (2019). Communication at transitions of care. Pediatric Clinics of North America, 66(4), 751–773. https://doi.org/10.1016/j.pcl.2019.03.004

This resource narrows down to communication errors during shift handover. Whether written or verbal, communication errors are among the major contributors to medication errors. This resource addresses not only the communication at nursing shift handoff but also the transfer of patients from one care provider to the next or between care institutions.

This article is useful in instilling the culture of medication safety during the care transition. Nurses who want to refer the patient to other medical professionals should adopt and implement the findings of this resource. It provides insights from research evidence that enable a deeper understanding of the role of communication in the development of medication and medical safety risks.

Conclusion

The presented resources address directly or indirectly various aspects of medication safety resulting from poor documentation or communication. The bedside shift reporting (BSR) was identified as the most appropriate toolkit to prevent medication safety risks. In this toolkit framework, the off-going and oncoming nurses have an opportunity to engage their patients in the care handover. Some of the above resources address the communication, implementation, assessment, and outcomes of using the BSR toolkit.

References

Anthony, M. K., Kloos, J., Beam, P., & Vidal, K. (2018). Innovative approach to reconstruct bedside handoff: Using simple rules of complexity science to promote partnership with patients. Journal of Nursing Care Quality, 33(2), 128–134. https://doi.org/10.1097/NCQ.0000000000000280

Bressan, V., Cadorin, L., Pellegrinet, D., Bulfone, G., Stevanin, S., & Palese, A. (2019). Bedside shift handover implementation quantitative evidence: Findings from a scoping review. Journal of Nursing Management, 27(4), 815–832. https://doi.org/10.1111/jonm.12746

Dorvil, B. (2018). The secrets to successful nurse bedside shift report implementation and sustainability. Nursing Management, 49(6), 20–25. https://doi.org/10.1097/01.numa.0000533770.12758.44

Ernst, K. M., McComb, S. A., & Ley, C. (2018). Nurse-to-nurse shift handoffs on medical-surgical units: A process within the flow of nursing care. Journal of Clinical Nursing, 27(5–6), e1189–e1201. https://doi.org/10.1111/jocn.14254

Forde, M. F., Coffey, A., & Hegarty, J. (2020). Bedside handover at the change of nursing shift: A mixed-methods study. Journal of Clinical Nursing, 29(19–20), 3731–3742. https://doi.org/10.1111/jocn.15403

Jakobsson, S., Ringström, G., Andersson, E., Eliasson, B., Johannsson, G., Simrén, M., & Jakobsson Ung, E. (2020). Patient safety before and after implementing person-centered inpatient care – A quasi-experimental study. Journal of Clinical Nursing, 29(3–4), 602–612. https://doi.org/10.1111/jocn.15120

Jimmerson, J., Wright, P., Cowan, P. A., King-Jones, T., Beverly, C. J., & Curran, G. (2021). Bedside shift report: Nurses’ opinions based on their experiences. Nursing Open, 8(3), 1393–1405. https://doi.org/10.1002/nop2.755

Patel, S. J., & Landrigan, C. P. (2019). Communication at transitions of care. Pediatric Clinics of North America, 66(4), 751–773. https://doi.org/10.1016/j.pcl.2019.03.004

Patton, L. J., Tidwell, J. D., Falder-Saeed, K. L., Young, V. B., Lewis, B. D., & Binder, J. F. (2017). Ensuring safe transfer of pediatric patients: A quality improvement project to standardize handoff communication. Journal of Pediatric Nursing, 34, 44–52. https://doi.org/10.1016/j.pedn.2017.01.004

White-Trevino, K., & Dearmon, V. (2018). Transitioning nurse handoff to the bedside: Engaging staff and patients. Nursing Administration Quarterly, 42(3), 261–268. https://doi.org/10.1097/NAQ.0000000000000298

Wollenhaup, C. A., Stevenson, E. L., Thompson, J., Gordon, H. A., & Nunn, G. (2017). Implementation of a modified bedside handoff for a postpartum unit. The Journal of Nursing Administration, 47(6), 320–326. https://doi.org/10.1097/NNA.0000000000000487

Wray, C. M., Arora, V. M., Hedeker, D., & Meltzer, D. O. (2018). Assessing the implementation of a bedside service handoff on an academic hospitalist service. Healthcare (Amsterdam, Netherlands), 6(2), 117–121. https://doi.org/10.1016/j.hjdsi.2017.06.002