Root-cause analysis and safety improvement plan

Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan

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

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

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.

1. Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;

1. Create a viable, evidence-based safety improvement plan for safe medication administration.

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

2. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

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

3. Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.

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

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

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.

Scenario

For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

. The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.

. The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

Instructions

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the 

Root-Cause Analysis and Improvement Plan [DOCX]
 template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

. Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.

. Create a feasible, evidence-based safety improvement plan for safe medication administration.

. Identify organizational resources that could be leveraged to improve your plan for safe medication administration.

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

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

.

Assessment 2 Example [PDF]
.

Additional Requirements

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

. Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

. APA formatting: Format references and citations according to current APA style.

Evidence-Based Practice

· Hande, K., Williams, C. T., Robbins, H. M., & Christenbery, T. (2017). 

Leveling evidence-based practice across the nursing curriculum.
 
The Journal for Nurse Practitioners, 13(1), e17–e22.

. Abstract: Evidence-based practice (EBP) competencies represent essential components of nursing education at all levels. The transition of EBP learning goals from the baccalaureate to the Master of Science in nursing and Doctor of Nursing Practice levels provides a blueprint for the development and advancement of student knowledge, skills, and attitudes. The purpose of this article is to describe 3 nursing curricula related to EBP competencies at the baccalaureate, master’s, and Doctor of Nursing Practice levels (Hande, Williams, Robbins, & Christenbery, 2017).

· Sukkarieh-Haraty, O., & Hoffart, N. (2017). 

Integrating evidence-based practice into a Lebanese nursing baccalaureate program: Challenges and successes.
 
International Journal of Nursing Education Scholarship, 
14(1), 441–442.

. Abstract: Evidence-based practice (EBP) is defined as “the conscientious use of current best evidence in making clinical decisions about patient care.” This paper describes how we have developed the evidence-based practice concept and integrated it into two courses at two different levels of the BSN curriculum. Students apply EBP knowledge and process by using the PICO clinical question (Population, Intervention, Comparison and Outcome), whereby they observe a selected clinical skill, and then compare their observations to hospital protocol and against the latest evidence-based practice guidelines. The assignment for the second course requires students to pick a more complex clinical skill and to support proposed changes in practice with scholarly literature. Assessment of student learning and course evaluation has shown that the overall experience of integrating EBP projects into the curriculum is fruitful for students, clinical agencies, and faculty (Sukkarieh-Haraty & Hoffart, 2017).

· Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). 

Readiness, barriers and potential strength of nursing in implementing evidence-based practice.
 
International Journal of Caring Sciences, 
13(2), 1203–1211.

. This article provides methods for identifying the readiness, barriers, and potential strengths of implementing evidence-based practice.

· Lee, S. K. (2016). 

Implementing evidence-based practices improves neonatal outcomes.
 
Evidence-Based Medicine, 
21(6), 231.

. This journal article provides a framework for identifying and appraising research, as well as implementing change and practices based on research.

Quality and Safety

· Ambutas, S., Lamb, K. V., & Quigley, P. (2017). 

Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units
. 
Medsurg Nursing, 
26(3), 175–179, 197.

. The implementation of a safety improvement project is examined in this article.

· Institute for Healthcare Improvement. (n.d.). 


Why is reducing harm 

–
 not just error – 
important to patient safety? [Video]


. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/Bates-Reducing-Harm-Important-To-Patient-Safety.aspx

. Based on the premise that human error may be reduced but not avoided in every health care situation, this video focuses on the importance of harm reduction to patient safety.

· The Joint Commission. (2018). 

2018 national patient safety goals
. https://www.jointcommission.org/standards_information/npsgs.aspx

. The patient safety resources on this Web page may be helpful as you develop the improvement plan section of your assessment.

· Mills, E. (2016). 

The WakeWings journey: Creating a patient safety program
. 
AORN Journal, 
103(6), 636–639.

. This article summarizes the creation of a safety program to reduce sentinel events.

·

U.S. Department of Health & Human Services
. (n.d.). https://www.hhs.gov/

. Explore numerous resources related to quality and safety on this website as you develop your assessment submission.

Root-Cause Analysis

· Institute for Healthcare Improvement. (n.d.). 


Cause and effect diagram

 [Video]
. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard16.aspx

. Cause and effect (or 
fishbone) diagrams are often used in root-cause analyses; this video shows how to create them.

· Institute for Healthcare Improvement. (n.d.). 

Introduction to trigger tools for identifying adverse events
. http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx

. Tools to identify adverse events and determine their causes are provided on this resource page.

· Galatzan, B. J. (2019). 

Exploring the content of the nurse-to-nurse change of shift hand-off communication (Publication No. 27666610) [Doctoral dissertation, University of Arizona].
 http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2336369734%3Faccountid%3D27965

. Abstract: An estimated 250,000 deaths occur annually are attributed to preventable medical errors. Approximately 100,000 of those deaths are related to miscommunication between healthcare providers. Miscommunication between healthcare providers during the transfer of care accounts for 80% of sentinel events occurring in the hospital setting. The hand-off communication continues to be one of the primary causes of sentinel events in healthcare in spite of the continued research focus over the past 10 years. The transfer of care communication between providers is called the “hand-off,” “change of shift report,” or “handover.” The hand-off for purposes of this study is defined as the process of transferring patient care, responsibility, and authority from one nurse to another at the change of shift. Specifically, we are concerned about the communication of clinical events (CE) experienced by the patient because CEs are precursors to a sentinel event. A CE is defined as a change in the patient’s condition in the following areas: bleeding, pain, fever, and changes in output, respiratory status, or level of consciousness (Galatzan, 2019).

· Minnesota Department of Health. (n.d.). 

Root cause analysis toolkit
. https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/

. The Minnesota Department of Health offers an extensive collection of resources related to root-cause analysis. 

· The Joint Commission. (n.d.). 

Framework for conducting a root cause analysis and action plan
. http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

. With resources for conducting a root-cause analysis and creating an action plan to address the results, this Web page will help you understand the steps and processes of RCAs and improvement plans for this assessment.

Safety and Sentinel Event Case Studies

· Institute for Healthcare Improvement. (n.d.). 

One dose, fifty pills (AHRQ)
. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx

· Institute for Healthcare Improvement. (n.d.). 


Josie King – What happened to Josie? 

[Video]
. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx