NURS 4020 Capella University Root Cause Analysis and Improvement Plan Discussion Essay

NURS 4020 Capella University Root Cause Analysis and Improvement Plan Discussion Essay

NURS 4020 Capella University Root Cause Analysis and Improvement Plan Discussion Essay

Root-Cause Analysis and Safety Improvement Plan

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Medication administration errors (MAEs) have been a great concern in my current healthcare organization. The most common perpetrated MAEs in the inpatient setting include wrong patient, wrong dosage, wrong drug, wrong administration route, omission of doses, and failure to document. These have resulted in poor health outcomes characterized by prolonged hospital stay, increased mortality, and high costs. A root-cause analysis (RCA) of MAEs was carried out in the inpatient units to identify the cause and impact. The purpose of this paper is to discuss evidence-based strategies to address MAEs, propose an evidence-based safety improvement plan, and identify resources that will facilitate the plan.

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Analysis of the Root Cause
In the adult medical unit, a novice nurse administered a diabetic patient 60 IU of mixtard insulin instead of the indicated 20 IU. This led to the patient’s blood glucose levels fluctuating abruptly than expected and getting into a hypoglycemic state. The attending physician noticed that the patient who was previously active and alert had suddenly developed confusion and was sweating and shaking. An RBS test was immediately taken and revealed the patient had sugar levels of 3.2 mmol/L. It was later established the patient had been administered an overdose of insulin.
The organization has had increased MAEs in the medical units with more and more patients developing adverse drug reactions (ADRs). The above medication error event led to an RCA being conducted by a team of healthcare professionals comprising a clinical pharmacist, a nurse in charge, a quality improvement officer, an RN from the unit, and an attending physician. The MAEs in the medical unit significantly affected patients’ outcomes due to adverse drug events (ADEs) that lead prolonged hospitalization, morbidity, mortality, and a rise in costs. It also affected the organization since the prolonged stays limited bed space for other patients and increased operational costs. Nurses were affected as the impact on patients led to an increased workload.
During the RCA, it was identified that the nurse did not report the medication error even after realizing it. The hospital’s policy states that MAEs are supposed to be reported since it is fundamental to preventing future errors. However, it was noted that nurses failed to report MAEs due to fear of consequences like punishment or losing a job when they self-reported. Besides, there were previous incidences where nurses were blamed for a patient’s ADRs after they reported MAEs. Nurses often fear being blamed for the reported MAEs in the working environment, legal issues, or losing their job after reporting errors (Nkurunziza et al., 2019). These factors have barred some nurses from self-reporting for fear of blame.
Furthermore, it was established that various organizational factors contributed to MAEs in the medical unit including a high workload, unhealthy nurse-to-patient ratio, and interruptions when administering medications. Moreover, nurse-related factors like aging, being a new nurse, limited work experience, fatigue, inadequate knowledge and skills about medication, and poor dosage calculation skills contributed to MAEs. Poor communication between nurses and physicians further contributed to MAEs and it was identified that some nurses fail to clarify doubts in prescriptions.
Application of Evidence-Based Strategies
The causes of MAEs are multifactorial and interrelated and usually arise from systems issues. Schroers et al. (2021) explain that MAEs are linked with individual factors like nurse fatigue and stress. Heavy workloads and a staff shortage contribute to fatigue, physical exhaustion, and inattention among nurses, which have been perceived to contribute to MAEs. Heavy nurse workload causes frequent interruptions, stress, and rushed performance, increasing MAEs. Furthermore, fatigue caused by heavy workloads has been linked with increased medication error incidences among providers in the ED (Westbrook et al., 2018). Disruptions, multitasking, and insufficient have been associated with high rates of prescribing errors, especially among providers in the ED. According to Bonafide et al. (2020), interruptions and distractions are the most frequent contextual factors that cause MAEs. Interruptions are prevalent in patient care settings and are linked with an increased frequency and severity of MAEs.
Since MAEs are multifactorial, multifactorial interventions are crucial to mitigate medication errors. Driscoll et al. (2018) revealed that ideal nurse staffing levels are associated with fewer MAEs and mortality. Thus, organizations should take the initiative to promote healthy nurse-to-patient ratios to reduce the workload for nurses and prevent ensuing fatigue and burnout. In addition, individual accountability among nurses should not be overlooked. Nurses should be trained and encouraged to make every effort to ensure they perform medication administration correctly and safely. Asefa et al. (2021) explain that MAE reporting helps to establish the primary causes of MAE and prevent future recurrence. When an error occurs, its effects can be mitigated through appropriate interventions, antidote administration, and appropriate guidelines.
Improvement Plan with Evidence-Based and Best-Practice Strategies
A self-reporting program for MAEs is the proposed safety improvement for safe medication administration. The program will require healthcare providers to report MAEs, including but not limited to the wrong patient, wrong drug, wrong dosage, wrong route, and omitting a medication (Mutair et al., 2021). Providers will also report the interventions they took to mitigate the adverse effects of the medication error and if the patient developed any ADRs. Besides, the MAE reporting program will require healthcare providers to identify the occurrence of MAEs and report them using official channels. It is widely known that self-reporting of MAEs is affected by fear of disciplinary action, the risk to job security, and perceived humiliation (Asefa et al., 2021). Therefore, it will be vital that the hospital appreciate self-reporting when developing self-reporting systems to prevent medical errors. The program will be designed to be safe for the reporting provider and will promote constructive and productive recommendations on how to improve drug administration. It will also include all providers and be supported with relevant resources.
Reporting of MAEs will provide constructive data to identify areas of improvement. When a medication error is reported, it will help mitigate its effects through correct medical interventions, administering antidotes, and using appropriate guidelines. Furthermore, reporting will help to identify areas that need additional education and training of providers to improve their work competencies. According to Mutair et al. (2021), reporting errors engages providers in opportunities for quality improvement and helps to establish the primary cause of the error. The anticipated outcome from error reporting is that it will decrease the number of future errors, improve patient outcomes, and lower financial costs.
The self-reporting program for MAEs will be developed within four weeks. It will be a long-term implementation project, but its outcomes will be evaluated after the first three months. This will help identify challenges with reporting and address them to foster self-reporting of errors among the providers. The program will then be reviewed every six months to establish its impact in reducing incidences of MAEs and improving patient safety.
Existing Organizational Resources
The organization will need to adopt a just culture to successfully implement the self-reporting program. A just culture encourages and rewards voluntary reporting. It also focuses on improving organizational systems and processes contributing to MAEs rather than individual blame and punishment Asefa et al. (2021). The organization has a policy that guides error reporting, which will be valuable in promoting the success of the proposed plan. In addition, the hospital has a system for reporting adverse events, which will be used to report MAEs.
Conclusion
MAEs have gradually increased in the hospital’s medical unit resulting in ADEs that contribute prolonged hospitalization and increased costs, morbidity, and mortality. MAEs have been linked to heavy workloads that cause fatigue and burnout, distractions, and lack of reporting. Furthermore, organizations should create channels that improve staff communication and working relationships among healthcare team members. Healthcare organizations should create channels that improve staff communication and working relationships among healthcare team members. My proposal is to establish a self-reporting program for MAEs, which will provide data to identify areas of improvement in drug administration and to promote patient safety.

References

Asefa, K. K., Dagne, D., & Mekonnen, W. N. (2021). Medication administration error reporting and associated factors among nurses working in public hospitals, Ethiopia: A cross-sectional study. Nursing Research and Practice, 2021, 1-8.
Bonafide, C. P., Miller, J. M., Localio, A. R., Khan, A., Dziorny, A. C., Mai, M., … & Keren, R. (2020). Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. JAMA pediatrics, 174(2), 162-169.
Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwaldt, D., McKee, G., Munyombwe, T., & Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of cardiovascular nursing, 17(1), 6–22. https://doi.org/10.1177/1474515117721561
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046
Nkurunziza, A., Chironda, G., Mukeshimana, M., Uwamahoro, M. C., Umwangange, M. L., & Ngendahayo, F. (2019). Factors contributing to medication administration errors and barriers to self-reporting among nurses: a review of literature. Rwanda Journal of Medicine and Health Sciences, 2(3), 294-303. https://doi.org/10.4314/rjmhs.v2i3.14
Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38-53. https://doi.org/10.1016/j.jcjq.2020.09.010
Westbrook, J. I., Raban, M. Z., Walter, S. R., & Douglas, H. (2018). Task errors by emergency physicians are associated with interruptions, multitasking, fatigue, and working memory capacity: a prospective, direct observation study. BMJ quality & safety, 27(8), 655–663. https://doi.org/10.1136/bmjqs-2017-007333

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NURS 4020 Capella University Root Cause Analysis and Improvement Plan Discussion

NURS 4020 Capella University Root Cause Analysis and Improvement Plan Discussion

Question Description

I’m working on a Nursing project and need support to help me study.

Find attached the “root cause analysis” as a word document needed for this assessment.

Find attached a sample of this assessment as a pdf.

nurs 4020 capella university root cause analysis and improvement plan discussion

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Find attached “assessment 1” which is talked about on the instructions for this assessment.

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 1 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.

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You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.

Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.

One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.

I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.

In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.

Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).

Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).

Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.

I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.

As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.

It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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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