Discussion: Root-cause analysis of a quality or safety issue in a health care setting

Question Description

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

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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.

Discussion: Root-cause analysis of a quality or safety issue in a health care setting

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.
  - Create a feasible, evidence-based safety improvement plan.
- Competency 2: Analyze factors that lead to patient safety risks.
  - Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
- Competency 3: Identify organizational interventions to promote patient safety.
  - Identify existing organizational resources that could be leveraged to improve a plan.
- 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.
- The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.
- One of the case studies from the previous assessment.
- A personal practice experience in which a sentinel event occurred.
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 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 in an organization.
- Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
- Create a feasible, evidence-based safety improvement plan.
- 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:
- 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. A title page is not required but you must include a reference list as per the template.
- 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.
Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information.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 evaluated.

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 in an organization.	Does not identify the root cause of a patient safety issue or a specific sentinel event in an organization.	Identifies the root cause of a patient safety issue or a specific sentinel event in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event.	Does not describe evidence-based and best-practice strategies.	Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event is unclear.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event, detailing how the strategies will address the safety issue or sentinel event.
Create a viable, evidence-based safety improvement plan.	Does not create a viable, evidence-based safety improvement plan.	Creates a safety improvement plan that lacks appropriate, convincing evidence of its viability.	Creates a viable, evidence-based safety improvement plan.	Creates a viable, evidence-based safety improvement plan 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.	Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan.	Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement are unclear.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan, 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.

Resources:

Discussion: Root-cause analysis of a quality or safety issue in a health care setting

· 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 ofevidence-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.ï»¿

· 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]. Retrieved from 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.
Joint Commission. (2018).2018 national patient safety goals. Retrieved from 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.
S. Department of Health & Human Services. (n.d.). Retrieved from https://www.hhs.gov/
- Explore numerous resources related to quality and safety on this website as you develop your assessment submission.

Discussion: Root-cause analysis of a quality or safety issue in a health care setting

· 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 (orfishbone) 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
- Tools to identify adverse events and determine their causes are provided on this resource page.
Mellinger, E. (2014).Action needed to prevent wrong-site surgery events. AORN Journal, 99(5), C5–C6.
- 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.

Discussion: Root-cause analysis of a quality or safety issue in a health care setting

· Sentinel Events

The Joint Commission. (2017).Sentinel event policy and procedures. Retrieved from https://jointcommission.org/sentinel_event_policy_and_procedures
- This Web page provides definitions, policies, and procedures related to sentinel events that may help you complete your assessment.
The Joint Commission. (2017).The essential role of leadership in developing a safety culture [PDF]. Sentinel Event Alert, 57, 1–8. Retrieved from https://www.jointcommission.org/sea_issue_57/
- 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 ofSentinel Event Alert discusses ways that effective leaders foster the development of a safety culture.

· Safety and Sentinel Event Case Studies

Vila Health: Root-Cause Analysis and Safety Improvement Planning.
- This Vila Health activity explores a root-cause analysis in the wake of a sentinel event and is one option you may use as context for your Root Case Analysis and Improvement Plan assessment.
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
- You may use one of these IHA case studies as context for your Root Case Analysis and Improvement Plan assessment if you prefer not to use the Vila Health activity or a problem from your own experience.

· Capella Writing Center

Introduction to the 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 thePublication 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

BSN Program Library Research Guide.
- 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.

Vila Health ® Activity

Root-Cause Analysis and Safety Improvement Planning

Introduction

Patient safety is a matter of more than just reacting to incidents as they arise.

To foster a truly safe environment for patients in a facility, one must look for broader patterns in safety concerns and trace them back to their common root causes. And, after these root causes have been identified, careful planning must be undertaken to enact evidence-based strategies to mitigate these issues.

In this scenario, you will assume the role of the charge nurse of a care unit at Clarion Court Skilled Nursing Facility in Shakopee, MN, a part of the Vila Health network. Clarion Court has seen a steady rise in medication errors over the past six months, leading to a particularly serious medication error last week that nearly resulted in an overdose.

The administrator of the facility, Stephen Silva, has asked you to conduct a root cause analysis and assist with creating a safety improvement plan to address the increase of medication errors on the unit over the past several months. This is a very serious matter because patient safety is of the utmost concern and medication errors remain a top priority at health care settings. You are required to submit a root cause analysis and safety improvement plan based off the incidences reported surrounding medication errors.

You have an email from Stephen Silva.

From: Stephen Silva, Administrator, Clarion Court Skilled Nursing Facility

Subject: RE: Safety at Clarion Court

I know that you’re upset about last week’s medication error. We all are. I think we need to look at this as a wake-up call, one we probably should have gotten months ago. We’ve seen the rate of medication errors move up steadily for months now, along with bad moves on several other health and safety metrics.

We need to take this seriously! On top of immediate measures to prevent the specifics of last week’s error from recurring, I would like you to do some examination of the deeper issues at play. Please spend some time talking to the care staff in your unit, and perform a root cause analysis. What are our underlying issues that are causing medication errors and other safety errors? On top of that analysis, I’d like you to at least start putting some thought into what sort of evidence-based courses of action we can undertake to remediate this.

Many thanks! I look forward to hearing what you find out.

best,
Stephen

Interviews

Team Member Statements

Click on each team member to gain insight into the safety concerns that will inform your safety improvement plan.

Marisa Pacheco

Director of Management Services

I’ve been here 6 months. In some ways, it feels like 6 years; in others, it feels like I’m still learning the ropes. One thing I have trouble with: the computer system we use for charts. I always think I get it, and then I get twisted around, and oh boy. It can get pretty confusing. A couple of times I’ve just gotten completely lost trying to enter basic information, and I get really upset and scared. And then it takes me forever to get out of the mess, and I fall behind. And if I have to ask for help, whoever it is that helps me falls behind, too.

It’s a really hard job. You get pretty fried by the end of a shift, especially if they change what shift you’re working on. I can get to be kind of a zombie after a couple of hours on my feet here. I had an incident – I still feel super bad about this – where I was helping a resident in the bath and she slipped because my attention drifted. She broke her hip, and had a really tough bunch of months after that. I felt terrible. And it all happened because I was zonked. I don’t handle meds, but I can’t imagine what it must be like for people trying to keep medications straight when their brains are mush at the end of a shift and they’ve been fighting with the computers the whole time.

Shonda McCrae

Discussion: Root-cause analysis of a quality or safety issue in a health care setting

I’ve been here three years. This was my first job after nursing school. I like it a lot! I love the connection with the residents – I feel like I’m doing my part to make their lives better a little bit each day.

In terms of safety, here’s the thing – in school and on the job here, I think I’ve had really good safety training. I know how to do things in ways that are safe for the residents and for me. I know the safety plan. But – but! Sometimes that training and those procedures don’t seem like they’re really meant for the real world. You always want to do things the right way, but then going completely by the book can be really fussy and take a long time. And you’ve got a million things to do and they’re all important and supposed to happen right now, and residents have needs and they’re urgent and, well, you get the picture. It’s a tough thing to balance, always following procedure and keeping up with your obligations.

Good example: I know one of the things that the state mentioned in their audit was a staff member not wearing gloves when touching a patient. Well, that was me. I’m not proud of that at all. But I was in the middle of doing a blood glucose check and my damn glove tore. I should have run and gotten another, but I didn’t have time, I was already behind. So I just yanked it off my hand and kept going, then I looked up and saw the inspector.

Anyway. I guess that means a bigger nursing staff would make everything safer, right? Less stuff for each person to do, more time to do it 100% according to protocol?

Lisa Cotrone

LPN

I’ve been here, what, 16 years. Wow! I spent a big chunk of time at Good Shepherd Home in St. Louis Park before that. It’s funny- I feel like I’m part of a dying breed. At least here, seems like all the incoming nurses are RNs, and a good chunk of them have a BSN.

Anyway. Safety. We get pulled into meetings, we get lectured about the safety plan, and, well, I don’t know. It’s good, yeah, but it’s words on paper. I’ve been here a long time! I know how to do things safely, no matter what some sheet of paper in a binder says.

One thing that happens to me again and again is that there’s this wall blocking communication. We do shift changeovers, and sometimes I have trouble following Fatima from the morning shift. Don’t get me wrong, she’s smart as heck! But she didn’t grow up speaking English, and her accent’s kind of thick. And sometimes the words she uses don’t make sense to me. And asking her to explain doesn’t always clear anything up. Couple of times, this has led to me not knowing something that’s up with a resident that I really should have known. We have charts, of course, and that helps, but charts only get you so far.

We get a lot of nurses and CNAs who either aren’t from the U.S. originally or are coming out of recent immigrant communities. I think there’s a couple of reasons for that. Partly because it’s a good entry-level job, and partly because in a lot of those cultures, it’s a definite thing that you should respect and take care of older people. And they see working here, or places like here, as a way to do that. And it’s great! But it means we have this language thing to deal with a lot.

Nora Church

You want to talk about safety? Sure, I can talk about safety.

The biggest problem we have is some of the support staff cutting corners or just not really knowing their jobs. I know I’m not supposed to say this, but I have a real problem trusting the CNAs to follow procedures. CNAs or other support staff. They don’t care about patient safety, they don’t respect the safety plan – what there is of it – and they don’t want to take the time to learn the right way of doing things, so they take short cuts so they can get on to their breaks or what have you. I trust the other RNs to do their jobs the right way. The LPNs too, I guess, although a lot of them have been carrying around a lot of bad habits for a long time. But outside of the credentialed nurses? Forget it.

There’s this really bad perception out there that skilled nursing facility staff aren’t on the same level as hospital staff. Which makes me crazy! It’s right there in the name, skilled nursing. But then I think of our CNAs here and, well, I see where people are coming from.

Rich Kim

CNA

You know something weird? I’ve been here for three years. That’s not long at all, really. But other CNAs come in and out of here so quickly that I feel like one of the old guard of Clarion Court. It’s a real problem!

It means that there are always a lot of people on the floor who are learning on the job. Even if they come in with very good job skills and experience, they still need time to familiarize themselves with Clarion Court itself. If you aren’t familiar with all of the residents, for instance, the older gentleman walking out the door with a firm look like he knows where he’s going may just appear to be a visitor on his way out when he is really a resident eloping. In fact, I think that’s happened here before.

Another thing that I think we need to do something about: nursing staff who walk around with their noses up in the air, thinking they’re too good to listen to CNAs when we’ve got something to say. I don’t care how fancy a nursing school you went to for your BSN, we’re all still people with eyes and brains, and we can all see stuff worth hearing about.

Reflection Questions

After talking to the floor staff, what do you see as some root causes of Clarion Court’s safety problems?

This question has not been answered yet.

What would you recommend as part of a safety improvement plan?

This question has not been answered yet.

Conclusion

Congratulations! You have completed this activity!