Root-Cause Analysis and Safety Improvement Plan

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Root-Cause Analysis and Safety Improvement Plan

Your Name

School of Nursing and Health Sciences, Capella University

NURS4020: Improving Quality of Care and Patient Safety

Instructor Name

Month, Year

Root-Cause Analysis and Safety Improvement Plan

Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.

Analysis of the Root Cause

Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:

· What happened?

· Who detected the problem/event?

· Who did the problem/event affect?

· How did it affect them?

Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:

· What was supposed to occur?

· Were there any steps that were not taken or did not happen as intended?

· What environmental factors (controllable and uncontrollable) had an influence?

· What equipment or resource factors had an influence?

· What human errors or factors may have contributed?

· Which communication factors may have contributed?

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

Application of Evidence-Based Strategies

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

· Describe what the literature states about the factors that lead to the safety issue.

· For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.

· Explain how the strategies could be addressed in safety issues or sentinel events.

Improvement Plan with Evidence-Based and Best-Practice Strategies

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

· Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.

· Support these recommendations with references from the literature or professional best practices.

· A description of the goals or desired outcomes of these actions.

· A rough timeline of development and implementation for the plan.

Existing Organizational Resources

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

· A brief note on resources that may need to be obtained for the success of the plan.

· Consider what existing resources may be leveraged to enhance the improvement plan?

Conclusion

References

Reference page should be double spaced throughout without extra spaces between entries.

Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.

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 in a health care setting of your choice as well as a safety improvement plan.

Introduction.

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.

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, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.

I NSTRUCTIONS

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 safety quality issue presented in your Assessment Supplement PDF in Assessment 1. 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, provide a rationale for your plan.

Use the  Root-Cause Analysis and Improvement Plan [DOCX]  Download 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 specific patient safety issue in an organization.

· Apply evidence-based and best-practice strategies to address the safety issue.

· Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.

· 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 but  keep in mind that your Assessment 2 will focus on the quality issue you selected in Assessment 1.

ADDITIONAL REQUIREMENTS

· Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to a specific patient safety issue.

· 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.

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

· Competency 1: Analyze the elements of a successful quality improvement initiative.

· Apply evidence-based and best-practice strategies to address the safety issue.

· Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.

· Competency 2: Analyze factors that lead to patient safety risks.

· Analyze the root cause of a specific patient safety issue in an organization.

· Competency 3: Identify organizational interventions to promote patient safety.

· Identify organizational resources that could be leveraged to improve your plan.

· Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Assessment 1

Enhancing Quality and Safety

For this assessment, you will develop a 3–5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Introduction

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

References

Allen, M. (2013).  How many die from medical mistakes in U.S. hospitals? https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000).  To err is human: Building a safer health system. National Academy Press.

PROFESSIONAL CONTEXT

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.

SCENARIO

Select one of the safety quality issues presented in the  Assessment 01 Supplement: Enhancing Quality and Safety [PDF]  Download Assessment 01 Supplement: Enhancing Quality and Safety [PDF]resource and incorporate evidence-based strategies to support communication and ensure safe and effective care.

Assessment 01 – Enhancing Quality and Safety

For this assessment, you will develop a 3–5-page paper that examines a safety quality issue in

a health care setting. You will analyze the issue and examine potential evidence-based and

best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Before you complete the instructions detailed in the courseroom, first select one of the safety

quality issues below to analyze for this assessment. After you have selected one of the issues

from the list below, return to the detailed instructions in the courseroom to complete your

assessment.

• LGBTQ+ and Transgender-Specific Care Needs: LGBTQ+ and transgender

individuals often face unique health challenges and disparities. A lack of knowledge or

sensitivity toward their specific needs can lead to inadequate care, discrimination, and

even avoidable health complications. Here's why addressing understanding and

addressing the specific needs of these populations is essential:

o Affirmation and Respect: Using correct pronouns, names, and understanding

the specific health needs of transgender and LGBTQ+ individuals can create an

environment of respect and affirmation. This respect is foundational to building

trust and ensuring that patients feel safe and understood in healthcare settings.

o Mental and Emotional Well-being: Due to societal stigmas and discrimination,

LGBTQ+ and transgender individuals may face higher rates of anxiety,

depression, and other mental health challenges. Being sensitive to these needs

and providing appropriate support is crucial for holistic care.

o Addressing Health Disparities: LGBTQ+ and transgender individuals might be

at higher risk for certain health issues. For instance, transgender women might

be at a higher risk for HIV/AIDS, while lesbian and bisexual women may be at a

higher risk for certain cancers. Knowledge of these disparities can guide

preventive care, screenings, and early interventions.

o Gender-Affirming Care: Transgender individuals might seek various medical

interventions as part of their transition, such as hormone therapies or surgeries.

Understanding the medical and emotional aspects of these treatments is crucial

for providing comprehensive care.

o Avoiding Discrimination: Discrimination or bias, whether overt or subtle, can

deter LGBTQ+ and transgender individuals from seeking care, adhering to

medical advice, or disclosing essential information about their health. Ensuring

an inclusive and non-discriminatory environment is vital for effective care

delivery.

o Sexual and Reproductive Health: LGBTQ+ individuals often face barriers in

accessing sexual and reproductive health services. Being knowledgeable and

non-judgmental about diverse sexual orientations and practices can lead to

better patient education and care in this domain.

o Social and Community Support: Recognizing the importance of community

and chosen family for many LGBTQ+ and transgender individuals can guide care

plans, especially when considering mental health support or discharge planning.

o Legal and Ethical Considerations: In many regions, there are legal protections

in place to ensure non-discrimination based on sexual orientation or gender

identity. Being aware of these protections is not only a legal obligation but an

ethical one, ensuring that all patients receive equitable care.

• Patient Identification Errors in Healthcare: Ensuring the correct identification of

patients is a foundational aspect of safe healthcare delivery. When errors occur in this

basic step, the ripple effects can be catastrophic. Here's why understanding and

preventing patient identification errors is essential:

o Patient Safety and Well-being: The most immediate and alarming consequence

of patient identification errors is the potential harm to the patient. Administering

the wrong medication, performing surgery on the wrong site, or providing

inappropriate treatments can lead to severe complications, prolonged recovery,

or even death.

o Loss of Trust: When patients or their families experience or witness

identification errors, their trust in the healthcare system can be severely eroded.

This loss of trust can make patients hesitant to seek care in the future or follow

medical advice, potentially compromising their health.

o Professional Reputation: For healthcare professionals, being involved in an

identification error can have lasting implications on their reputation. Such errors

can lead to disciplinary actions, loss of licensure, or legal consequences.

o Legal and Financial Implications: Patient identification errors can result in

lawsuits, leading to significant financial penalties for healthcare institutions.

Beyond the direct costs of litigation, there's the potential for increased insurance

premiums and the costs associated with implementing corrective measures.

o Operational Disruptions: Identification errors can disrupt the normal flow of

operations in a healthcare setting. They may necessitate additional tests,

procedures, or interventions to correct the error, leading to delays and

inefficiencies.

o Emotional Toll on Healthcare Providers: Realizing that one has been involved

in an identification error can be emotionally devastating for healthcare providers.

Feelings of guilt, anxiety, and doubt can lead to burnout and may even cause

some professionals to question their career choice.

o Increased Healthcare Costs: Beyond the direct costs associated with correcting

the error, there are indirect costs to consider. These might include extended

hospital stays, additional treatments, and the long-term care needs of patients

who experience complications due to the error.

o Regulatory and Accreditation Implications: Healthcare facilities are subject to

regulations and standards set by accrediting bodies. Identification errors can lead penalties, increased scrutiny, and potential challenges in maintaining

accreditation.

INSTRUCTION

For this assessment, you will analyze a safety quality issue in a health care setting and identify a quality improvement (QI) initiative.

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 that you know what is needed for a distinguished score.

· Explain factors leading to a specific patient-safety risk in a health care setting.

· Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.

· Explain how nurses can help coordinate care to increase patient safety and reduce costs.

· Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.

· Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

ADDITIONAL REQUIREMENT

· Length of submission: 3–5 pages, plus title and reference pages.

· Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

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

COMPETENCIES MEASURED

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

· Competency 1: Analyze the elements of a successful quality improvement initiative.

· Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.

· Competency 2: Analyze factors that lead to patient safety risks.

· Explain factors leading to a specific patient-safety risk in a health care setting.

· Competency 4: Explain the nurse's role in coordinating care to enhance quality and reduce costs.

· Explain how nurses can help coordinate care to increase patient safety and reduce costs.

· Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.

· Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.