Capella NURS FPX4020 Root Cause Analysis and Safety Improvement Plan Project

Capella NURS FPX4020 Root Cause Analysis And Safety Improvement Plan Project

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a healthcare setting of your choice and outline a plan to address the issue.

Assessment 2 Instructions: 

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a healthcare 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

Assessment 2 ;Example [PDF].

Medication Errors Root Cause Analysis and Safety Improvement Plan Sample Paper

Root cause analysis (RCA) is a tool used to investigate and understand the underlying causes of patient safety incidents such as medication errors (Ahmed et al. 2019). It helps in problem identification so that health practitioners can introduce changes that improve care quality and patient experience. Medication errors is a typical incident that requires an RCA that will ultimately produce various recommendations to reduce medication errors and improve patient safety. 

The application of RCA to medication errors within a clinical care setting is especially important considering the alarming numbers of increased length of stay, hospital injuries and death that adverse events have caused in American hospitals (Gates et al. 2019). For instance, according to Mazer and Nabhan (2019), at least 200,000 deaths are attributable to medication errors yearly, indicating that there are various root cause factors that play a role in those events, and that are worth exploring. 

This report covers an RCA of ten hospitals in the US, analyzing and describing the fundamental causes and major contributors to medication errors, as well as an evidence-based plan and resources for improving patient safety.  

Root Causes Of Medication Errors And Evidence-Based Solutions

When nurses, pharmacists or physicians offer any type of healthcare service to patients, they can unknowingly inflict injury on the patient or cause adverse events such as medication errors or misdiagnosis. As per Gates et al. (2019) 10-20% of medication orders contain medication errors depending on the adverse event, for instance delayed medicine administration. However, Gates et al. (2019) also found out that serious medication errors make up 5% of medication administrations in the US.  In the case of Delaware Community clinic, the management reports collected over the past 30 days indicated that for every 100 medication administration cases, seven of errors are experienced. This number is above the acceptable rate of medication errors.

The data was collected through direct and non-participant observations of medication preparation and delivery. The non-participatory observation of medication errors yielded important information about medication errors. For example, it was observed that distractions and secondary events were among the direct causes of medication errors in the Delaware Community clinic. 

While most medication errors are preventable, they cause an array of adverse events such as triggering new health conditions, patient injury, or in worst cases, death (Ibrahim et al. 2020). Medication errors also lengthen hospital stay, increases cost of healthcare, and inflicts psychological or physical pain to the patient and their families. Regarding healthcare organizations, medication errors reduce patient satisfaction and ultimately contribute to trust issues towards the nurses, physicians, and entire health organization.

The RCA was conducted by a team of six practitioners including a clinician, a supervisor, two quality improvement personnel and two nurses. Through nurse observations, the medication errors were recorded with an emphasis on medication ordering and administration services. The error cases were categorized under prescription omission, wrong timing, improper usage, dose preparation and dosage, medication administration errors including extra dosage and giving the to the wrong patient.

The observed incidences revealed that time, unauthorized administration, and dosage errors were the most prevalent, accounting for 17, 10 and 18 percent of the medication errors respectively. The observations also indicated that the errors occur during the periods of high activity, for instance during shift changes and during emergency calls. The RCA also showed that staff-related causes of medication errors were attributable to inadequate pharmacological knowledge. For instance, it was observed that nurses who lacked the ideal knowledge of the ideal medication administration route were likely to cause incidences of intravenous injections.

The errors were also observed to be highly associated with poor knowledge of drug pharmacological properties as well as excessive dosage. These errors were observed to be primarily caused by the complex nature of intravenous medication, which require vast experience to deliver the drug as optimally as possible.

Particularly, the nurses who made these mistakes showed a lack of in-service training among newer staff, which constrained them of the necessary knowledge needed to prepare and deliver the drugs. as recommended by Mazer & Nablan (2019), in-service training on pharmacology and administration of complex medicine could be a good approach to reducing such medication errors.

The second root cause of medication errors in the Delaware Community clinic was a shortage of nurses, which increased the workload of nurses needed at one point in time. Interviewed nurses revealed that medication errors were highly attributable to understaffing because nurses were under pressure to cover all the workload. 

Therefore, some evidence-based solution to understaffing is employing more nurses, ensuring a smoother change of shifts, and supporting the nursing staff as much as possible (Mazer & Nabhan, 2019). For instance, during the root cause analysis, it was observed that some laboratory staff could call the physicians to physically collect the lab results, yet the results could easily be transmitted to the physician using the electronic medical records system (EMRs).

Rezaei (2019) recommends that EMRs can reduce medication errors by facilitating fast, efficient, and reliable transmission of patient information between nurses, pharmacists, laboratory technicians and the patient. Using technology to transmit important information such as lab reports could help minimize the pressure that comes with physically handling the data.

Improvement Plan

The improvement plan following this RCA will take two approaches namely improvement of staffs’ skills and knowledge and making the necessary environmental changes to minimize medication errors. The first item of the plan is to improve the hospital’s medication monitoring system to improve staff coordination and enhance prescription accuracy through various cross-checking points and communication among staff. 

The second improvement plan will be to train the staff on how to prevent medication errors, especially when administering complex medications such as intravenous injections. The training should improve the nurses’ pharmacological knowledge especially on new drugs, contraindications, dosages, and proper administration.

Conclusion

Medication errors are associated with lengthened hospital stays, injury, increased care costs and even death. An RCA of the factors contributing to medication errors revealed important information on some of the leading causes as well as their potential solutions. The report indicated that nurse lack of skills and knowledge, followed by poor communication and distractions are the most common causes of medication errors. 

Some of the evidence-based strategies for addressing the problem include improvement of staffs’ skills and knowledge and making the necessary environmental changes to minimize medication errors. These two solutions will provide a ground approach to minimizing medication errors in Delaware Community hospital.

References

• Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14. https://doi.org/10.1371/journal.pone.0217023
• Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931-939. https://doi.org/10.1007/s40264-019-00823-4
• Ibrahim, O.M., Ibrahim, R.M., Meslamani, A.Z.A., & Mazrouei, N.A. (2020). Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes. Pharmacy Practice (Granada), 18(4), 2111. https://doi.org/10.18549/PharmPract.2020.4.2111
• Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267. https://doi.org/10.1007/s11606-019-05156-7