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.
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
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