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Assessment: Root Cause Analysis and Safety Improvement Plan

Assessment: Root Cause Analysis and Safety Improvement Plan

Assessment: Root Cause Analysis and Safety Improvement Plan

Question Description

See the attachment

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

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  • PRINT
  • 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.

  • SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluated.

VIEW SCORING GUIDE

Resources: Evidence-Based Practice

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      • 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.

Resources: Quality and Safety

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      • 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.

Assessment: Root Cause Analysis and Safety Improvement Plan

Resources: Root-Cause Analysis

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  • PRINT
  • 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.

Resources: Sentinel Events 

Assessment: Root Cause Analysis and Safety Improvement Plan

Top of Form

Bottom of Form

      • 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.
Resources: Safety and Sentinel Event Case Studies
  • PRINT

·         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

Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan • PRINT • For this assessment, you will use a supplied template to conduct a rootcause 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. ; • • 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. • • Create a viable, evidence-based safety improvement plan for safe medication administration. 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 evaluated. VIEW SCORING GUIDE Resources: Evidence-Based Practice • PRINT • 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. Resources: Quality and Safety • PRINT • 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. • • 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/BatesReducing-Harm-Important-To-Patient-Safety.aspx • • The implementation of a safety improvement project is examined in this article. 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. U.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. Resources: Root-Cause Analysis • PRINT • 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 • • 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. • • Cause and effect (or fishbone) diagrams are often used in root-cause analyses; this video shows how to create them. 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_A nalysis_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. Resources: Sentinel Events • PRINT • 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 of Sentinel Event Alert discusses ways that effective leaders foster the development of a safety culture. Resources: Safety and Sentinel Event Case Studies • • PRINT 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/Page s/Activities/AHRQCaseStudyOn eDoseFiftyPills.aspx Institute for Healthcare Improvement. (n.d.). Josie King What happened to Josie? [Video]. Retrieved from http://www.ihi.org/education/ IHIOpenSchool/resources/Page s/Activities/WhatHappenedtoJ osieKing.aspx Root-Cause Analysis and Safety Improvement Plan Scoring Guide CRITERIA NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D 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 evidencebased and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration . Does not describe evidence-based and bestpractice strategies pertaining to medication administration. Describes evidencebased and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear. Applies evidencebased and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration . Applies evidence-based and bestpractice 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 CRITERIA NONPERFORMANC E BASIC PROFICIENT DISTINGUISHE D medication administration. Create a viable, evidencebased 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, evidencebased 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 Does not communicate safety improvement Communicate s safety improvement plan using Communicate s safety improvement plan using Communicates safety improvement plan using CRITERIA plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. NONPERFORMANC E plan using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. BASIC PROFICIENT DISTINGUISHE D writing that is unclear, illogical, and/or contains numerous errors in grammar or APA style. writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. writing that is clear, logical, and professional, with correct grammar and spelling, using current, errorfree APA style. Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis and Safety Improvement Plan YOUR NAME NURS-FPX4020 Capella University Month, Year 1 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings. Analysis of the Root Cause Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as: • What happened? • Who detected the problem/event? • Who did the problem/event affect? • How did it affect them? Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as: • What was supposed to occur? o Were there any steps that were not taken or did not happen as intended? • What environmental factors (controllable and uncontrollable) had an influence? • What equipment or resource factors had an influence? • What human errors or factors may have contributed? • Which communication factors may have contributed? 2 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event. Application of Evidence-Based Strategies Identity best practices strategies to address the safety issue or sentinel event. • Describe what the literature states about the factors that lead to the safety issue. o For example, interruptions during medication administration increase the risk of medication errors by specifically stated data. o Explain how the strategies could be addressed in safety issues or sentinel events. Improvement Plan with Evidence-Based and Best-Practice Strategies Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain: • Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes. o Support these recommendations with references from the literature or professional best practices. • A description of the goals or desired outcomes of these actions. • A rough timeline of development and implementation for the plan. Existing Organizational Resources Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan. o A brief note on resources that may need to be obtained for the success of the plan. 3 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN o Consider what existing resources may be leveraged to enhance the improvement plan? 4 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN o Conclusion References 5 Running head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN Root-Cause Analysis and Improvement Plan Learner’s Name Capella University Improving Quality of Care and Patient Safety Root-Cause Analysis and Improvement Plan March, 2019 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 1 ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 2 Root-Cause Analysis and Improvement Plan According to Spath (2011), root-cause analysis is a methodical approach that aims to discover the causes of adverse events and near misses for the purpose of identifying preventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls in geropsychiatric patients was conducted at an inpatient mental health unit. The paper describes and analyzes falls and discusses evidence-based strategies to reduce falls and determine a safety improvement plan based on the utilization of existing organizational resources to address these falls. Root-Cause Analysis of Falls in Geropsychiatric Inpatients According to Murphy, Xu, and Kochanek (2013), the …

 

 

 

 

 

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