Root Cause Analysis and safety improvement plan

Root Cause Analysis and safety improvement plan

 

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

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

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

Demonstration of Proficiency

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

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

• • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
  • Create a viable, evidence-based safety improvement plan for safe medication administration.
• Competency 2: Analyze factors that lead to patient safety risks.

• • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
• Competency 3: Identify organizational interventions to promote patient safety.

• • Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
• Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

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

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.

 

Root-Cause Analysis and Safety Improvement Plan Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Does not identify the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Does not describe evidence-based and best-practice strategies pertaining to medication administration.	Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration, detailing how the strategies will address the safety issue or sentinel event pertaining to medication administration.
Create a viable, evidence-based safety improvement plan for safe medication administration.	Does not create a viable, evidence-based safety improvement plan for safe medication administration.	Creates a safety improvement plan for safe medication administration that lacks appropriate, convincing evidence of its viability.	Creates a viable, evidence-based safety improvement plan for safe medication administration.	Creates a viable, evidence-based safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for safe medication administration are unclear.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration, prioritizing them according to potential impact.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Does not organize content for ideas. Lacks logical flow and smooth transitions.	Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling.	Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.	Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.	Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

 

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Solution

Root-Cause Analysis and Safety Improvement Plan

Medication errors are unfortunate realities within the US healthcare system that continues to occur at alarming rates. These events impact all the healthcare stakeholders, including patients, families, healthcare providers, and insurers (Treiber & Jones, 2018). To curb this quality and safety issue, the Joint Commission requires hospitals to occasionally conduct an analysis of sentinel events. One of the commonly utilized processes in the exercise is the root cause analysis (RCA) (Hibbert et al., 2018). Healthcare institutions can optimize patient care through the RCA process and enact measures to mitigate adverse events that compromise patient safety. For example, this easy will review a medication error case involving a 29-year-old female patient treated in an obstetric emergency department. I will employ RCA to identify the root cause of the problem and use the findings to develop a safety improvement plan.

Analysis of the Root Cause

A 29-year-old female at 33 weeks gestation with a history of gestational hypertension presented to the obstetric emergency at midnight with shortness of breath, blurry vision, severe headache, and right upper abdominal pain. She also reported nausea and vomiting in the past three hours. The patient reported the onset of the symptoms to be five hours ago and was associated with a gradual increase in lower extremity edema. The patient is currently taking labetalol prescribed two weeks ago when she was diagnosed with gestational hypertension. Vital takings indicated elevated blood pressure and a significant weight gain since her last check-up five days ago. Diagnostic tests showed excess proteins in the urine and decreased levels of platelets in the blood, indicating a pre-eclampsia diagnosis. The physician ordered IV magnesium sulfate to prevent seizures, injuries to the baby’s brain, and preterm labor by relaxing smooth muscle tissues. The hospital has a standard protocol that requires magnesium sulfate to be administered as 4-gram IV and 10-gram IM regimen in each buttock. The prescription was communicated to the nurse verbally, who prepared it incorrectly due to the rash caused by the urgency of the situation. The poster on magnesium sulfate’s preparation previously placed on the drug preparation room had become faded and had not yet been replaced. Therefore, the nurse relied on her memory during the preparation of the prescription and did not countercheck the medicine with another nurse as per the hospital protocol. Twenty minutes later, the patient started becoming lethargic. She reported severe muscle weaknesses, fatigue, flushing, and dizziness. The attending nurse suspected these to be side effects of magnesium sulfate. She consulted another nurse and repeated the dose strength aloud to her, who crosschecked it from a printed chart and picked up the error in the already administered drug. The case was reported to the senior obstetric resident, who immediately prescribed IV Calcium gluconate, an antidote for magnesium sulfate. She was also put on oxygen therapy and iv fluids.

In this medication error case, several factors contributed to the problem. These include communication deficits among medical staff members, poor implementation of safety and quality protocols, and non-adherence to the implemented protocols by healthcare workers. To start with, the physician verbally provided the order for magnesium sulfate administration to the nurse. Verbal communication of prescriptions poses a significant risk of errors. There is also a deficiency in the hospital protocols regarding the standard protocol through which medications should be communicated. Secondly, the facility management’s poor implementation of safety protocols is evident where the chart displaying magnesium sulfate’s preparation in the drug preparation room had become faded and has not yet been replaced. Therefore, the nurse prepared the medication relying on her memory. In addition, despite standard protocols to countercheck the dose of high-risk medicine, the nurse overlooked the protocol and administered the drug without counter-checking the dose. This indicates poor adherence to the already implemented hospital safety protocols.

Application of Evidence-Based Strategies

Various studies focusing on medication errors have resulted in multiple evidence-based recommendations for addressing the issues. The factors contributing to medication error in the current case can be addressed through evidence-based approaches. Communication deficits among medical staff members can be addressed rough implementation of communication protocols in a healthcare facility (Treiber & Jones, 2018). It is essential to have a standardized protocol for communication among care providers to ensure passing of accurate information regarding patient medication administration. These can help prevent errors arising from verbal communication of prescriptions (Mutair et al., 2021).

Poor implementation of safety and quality protocols within an organization can impair adherence by healthcare workers. Once implemented, policy actions need to be put in place to inform and educate the providers on how to integrate the recommendations into practice; resources have to be provided to facilitate the adoption of the practice and surveillance and monitoring protocols to enhance adherence (Hibbert et al., 2018). In addition, policies on how to deal with non-adherence are essential. For instance, in the current case, poor protocols regarding how and when the faded charts regarding the protocols should be replaced contributed to the medication error. Ensuring that staff members can readily access essential updates and protocol changes can help in adherence to the safety protocols. Besides, poor monitoring of the protocols resulted in mistakes. The attending nurse intentionally failed to follow the hospital protocol regarding

crosschecking medication dose with another nurse before administering the prescription. If there was proper monitoring of adherence to the safety and quality protocols, such errors could be prevented. Poor knowledge regarding the medicine could have contributed to error as well. There is therefore a need for regular training of nurses about medication risks and the newly developing therapies. As direct caregivers and care coordinators in multidisciplinary care teams, nurses are involved in medication administration in most parts of their practice. They need to be informed on high-risk medications requiring extra caution during administration.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The quality improvement plan that should be implemented in the facility to address the discussed medication error scenario should focus on issues identified in the case. These include both improvements of the current protocols and implementation of new protocols. First, to promote better communication of prescriptions among physicians and nurses, there is a need to implement standard prescription communication channels, such as written or electronic communication. This ensures nurses can refer to the prescription written by the physician and confirm it to prevent the risk of errors (Rudzewicz, Houseman & Hipskind, 2021).

Secondly, to improve access to the already implemented safety protocols regarding drug administration, there is a need for new policies to enhance access, such as electronic availability of drug charts and quality maintenance of wall charts to ensure information is visible thus reliable by the providers (Hibbert et al., 2018). Besides, the facility needs to introduce policies enabling regular training of nurses on the newly developing pharmaceutical products and their safety risks. Finally, the facility also needs to implement surveillance areas to monitor nurse adherence to the already implemented medication administration safety and quality measures. This plan aims to enhance security in medication administration by promoting better communication among providers and commitment to the readily implemented protocols (Tariq et al., 2018).

The plan implementation will take four weeks. The first week will entail developing the policy changes by a multidisciplinary team. The second and third weeks will entail resource consolidation, while implementation will occur in the fourth week.

Existing Organizational Resources

           The organization resources that will help improve the plan’s implementation and outcome include a multidisciplinary care team consisting of physicians, nurses and nurse informaticists. Besides, the facility library materials, including computers, will be essential in disseminating data on the current protocol to the care providers. Financial resources will help fund research studies to help prepare educational programs on current developing therapies. The existing surveillance resources will help monitor adherence to the new protocols.

Conclusion

Despite the increasing prevalence of medication errors and their adverse effects, they are preventable through evidence-based practices. However, the first step in addressing the issue is establishing the causes of the problem. This helps design a targeted plan to resolve the issue.

 

 

References

Hibbert, P. D., Thomas, M. J., Deakin, A., Runciman, W. B., Braithwaite, J., Lomax, S., … & Fraser, C. (2018). Are root cause analyses recommendations effective and sustainable? An observational study. International Journal for Quality in Health Care, 30(2), 124-131. https://doi.org/10.1093/intqhc/mzx181

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., … & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046

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

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention. https://europepmc.org/article/NBK/nbk519065

Treiber, L. A., & Jones, J. H. (2018). After the medication error: Recent nursing graduates’ reflections on adequacy of education. Journal of Nursing Education, 57(5), 275-280. https://doi.org/10.3928/01484834-20180420-04