Presentation: Root Cause Analysis and Safety Improvement Plan

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.

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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.

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.

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.

SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluate

Resources: Evidence-Based Practice

Evidence-Based Practice

Giomuso, C. B., Jones, L. M., Long, D., Chandler, T., Kresevic, D., Pulphus, D., & Williams, T. (2014). A successful approach to implementing evidence-based practice. Med-Surg Matters, 23(4), 4–9.

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

ROOT-CAUSE ANALYSIS

SENTINEL EVENTS

SAFETY AND SENTINEL EVENT CASE STUDIES

Assessment 3 Instructions: Improvement Plan In-Service Presentation

For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.

As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.

The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel Wright, 2018).

As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.

You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies – especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.

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.

- Explain the need and process to improve safety outcomes related to medication administration.
- Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.

- List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
- Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

Reference

Patel, S., Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic, Neonatal Nursing, 47(3), s16-s17.

PROFESSIONAL CONTEXT

As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.

SCENARIO

For this assessment it is suggested you take one of two approaches:

Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or

2.Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.

INSTRUCTIONS

The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at ;an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your presentation 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.

List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Explain the need for and process to improve safety outcomes related to medication administration.
Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

There are various ways to structure an in-service session below is just one example: Presentation: Root Cause Analysis and Safety Improvement Plan

Part 1: Agenda and Outcomes.

- Explain to your audience what they are going to learn or do, and what they are expected to take away.
Part 2: Safety Improvement Plan.

- Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
- Explain why it is important for the organization to address the current situation.
Part 3: Audience’s Role and Importance.

- Discuss how the staff audience will be expected to help implement and drive the improvement plan.
- Explain why they are critical to the success of the improvement plan focusing on medication administration.
- Describe how their work could benefit from embracing their role in the plan.
Part 4: New Process and Skills Practice.

- Explain new processes or skills.
- Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
- In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
Part 5: Soliciting Feedback.

Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
Explain how you might integrate this feedback for future improvements.

Remember to account for activity and discussion time.

ADDITIONAL REQUIREMENTS

Presentation length:There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be 10–15 slides.
Speaker notes: Speaker notes should reflect what you would actually say if you were delivering the presentation to an audience. Another presenter would be able to use the presentation by following the speaker notes.
APA format:Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
Number of references:Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.

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.

Presentation: Root Cause Analysis and Safety Improvement Plan

Resources: Leadership Competencies

LEADERSHIP COMPETENCIES

EVIDENCE AND VALUE-BASED DECISION MAKING

FACILITATING LEARNING

Requirements: .doc file

ATTACHMENTS

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