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Discussion: Root Cause Analysis of Medical Errors

Discussion: Root Cause Analysis of Medical Errors

Discussion: Root Cause Analysis of Medical Errors

Question Description

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.

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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

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 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 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.

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.

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.

 

 

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.
Communicate safety improvement plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Does not communicate safety improvement plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Communicates safety improvement plan using writing that is unclear, illogical, and/or contains numerous errors in grammar or APA style. Communicates safety improvement plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Communicates safety improvement plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current, error-free APA style.

 

Evidence-Based Practice

    • This article provides a baseline definition of evidence-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

    • 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.
  • Joint Commission. (2018). 2018 national patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx
    • 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]. Retrieved from 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. Retrieved from http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
    • This article examines the role nurses play in preventing and examining sentinel events.
  • Minnesota Department of Health. (n.d.). Root cause analysis toolkit. Retrieved from 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. Retrieved from 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.

Sentinel Events

    • 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

  • Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ).;Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
  • Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. Retrieved from http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx

Capella 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

    • 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.

 

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