Assignment: Root Cause Analysis and Safety Improvement Plan Report

Root-Cause Analysis and Safety Improvement Plan

In a root-cause analysis of medication errors in patients at an inpatient mental health unit, one such situation that occurred is wrong medication administration. For example, a staff nurse administered incorrect doses of medications to two separate patients under the same physician’s care, resulting in adverse effects. One patient experienced drowsiness and confusion due to the improper dosage, while the other experienced muscle spasms and headaches. When these symptoms became obvious, it was the staff nurse who first detected the problem, documenting their findings within the electronic medical record for both patients. Allergic reactions were fortunately avoided since appropriate dosages of known allergen meds had been avoided, thus avoiding potentially life-threatening situations (Morrison et al., 2019). Evidence-based strategies are recommended to reduce medication errors and provide a safety plan to ensure proper action is taken if similar events occur in the future. Strategies recommended include training remains prepared with the knowledge necessary to identify and react accordingly to prevent a recurrence. Additionally, ensuring that all clinicians have good communication practices helps reinforce accountability standards and avoids oversights when prescribing medications or transferring information between departments or colleagues. Further recommendations will be explored during further evaluations for a complete safety improvement plan incorporating an identified cause-and-effect relationship between target objectives and expected outcomes, thus bettering patient outcomes overall.

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Root-Cause Analysis

When a nurse failed to check the dosage of medication, it had profound consequences. A staff member in charge noticed that the original dose packet was missing and replaced it with one with a higher dosage which provided an incorrect amount of medication for the patient. This error in judgment led to unexpected effects such as the patient vomiting and their blood pressure dropping after half an hour. Upon analysis, it became apparent that the nurses should have taken additional steps such as monitoring the patient, but they likely overlooked this due to a lack of resources. Additionally, environmental factors such as the absence of a necessary file on the patient’s medication compounded matters further (Trakulsunti et al., 2021). In hindsight, if further measures such as having a second nurse double-check dosages had been employed, then perhaps this error could have been avoided or mitigated (Lilley et al., 2022).

According to the Centers for Disease Control and Prevention (CDC), medication errors exist due to a variety of causes, such as prescribing medications in ways that are unclear or failing to provide necessary patient information. Additionally, some mistakes arise from faulty drug distribution processes, unclear labeling of medications, or incomplete communication by providers and healthcare workers. Unfortunately, such errors can lead to serious harm due to incorrect use of medications or adverse effects (Xu et al., 2020). To help address the issue of medication errors, the CDC suggests decreasing distractions while administering drugs; using unit-dose dispensed medications; developing systems legal changes and updates; ensuring quality control measures are in place; improving education initiatives; avoiding clinician fatigue; and following standard protocols for both pre-and postadministration. By taking these steps, organizations can help reduce the incidents of medication errors and any associated risks.

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Medication errors and wrong dosages of prescribed medicines can have serious adverse implications, such as medication-related harm, increased hospital and outpatient costs, as well as patient mortality. Three root causes are often reported regarding medication errors and wrong dosage: human factors (lack of knowledge, fatigue, and skill), organizational factors (poor communication within the healthcare organization, inadequate staffing levels, complex drug inventory management systems), and environmental factors (uncontrollable such as unclear handover requirements or lack of computerized prescribing; controllable such as malfunctioning equipment). Research indicates that between 30-100% of medication errors can be prevented or reduced depending on the safety interventions implemented. In order to successfully prevent or reduce medication errors, various actions may be taken including professional development initiatives for healthcare worker training on pharmacology principles, updated clinical practice guidelines for drug administration, the introduction of evidence-based checklists to reduce the likelihood of potential drug misregulation and computerized prescribing systems for improved accuracy (Rodziewicz & Hipskind, 2020). Safety surveillance systems should also be implemented in order to identify any existing problems or potential safety risks. Furthermore, policy recommendations from bodies such as The Joint Commission can promote best practices with regard to rigorous staff education regarding medication safety.

Analyzing Factors

Patient medication errors are a preventable cause of harm to healthcare, and identifying evidence-based findings and best-practice strategies is necessary to mitigate its risk. In the mental health unit, one of the most effective ways to reduce the potential for nurse-administered medication errors is patient education (Trakulsunti et al., 2021). Effective patient education provides patients with a greater understanding of their meds, and as a result, increases monitoring efforts such as noticing whether a right or wrong dose is taken at any instance or if the prescribed drug matches their regimen. Accurate documentation within a comprehensive electronic health record system also aids in decreasing patient medication errors. Proper entry of doses, times, and drug actions can accelerate more carefully planned interventions which improve the quality and safety of care (Blignaut et al., 2017). Moreover, the use of the 5 rights (right drug, right time, right route, right dose, and right person) provides nurses with an established protocol to follow when administering medications; furthermore, it also serves as an additional method for nurses to double check that they are giving the correct drug at the appropriate time and serving to avoid dangerous interactions. Taken together, incorporating evidence-based findings such as patient education, strategic utilization of comprehensive EHR systems, and practicing the 5 rights can bolster nurse competency while concurrently providing an additional layer of security against inadvertently administering wrong medications.

Application of Evidence-Based Strategies to Reduce Medication Errors

Reducing medication errors and preventing the wrong dosage of medication administration requires thoughtful evidence-based strategies. One example of this is patient education, whereby healthcare professionals provide detailed information to the patient about their medications, such as possible side effects, intended purpose, and how to administer the medication. Besides patient education, another important strategy is accurate documentation within a comprehensive electronic health record system. Having all necessary information in one accessible system helps reduce errors by providing healthcare providers with relevant information related to a corresponding patient’s prescribed medications (Halli-Tierney et al., 2019). Lastly, nurses should follow a “five rights” approach when administering medications; namely ensuring that the patient receives the right drug, at the right dose, via the right route at the right time for therapeutic benefits. With these evidence-based strategies in place, nurses can reduce medication errors and decrease the wrong dosage of medication administration.

Improvement Plan

An effective improvement plan to reduce medication errors must address three strategies; training and education of nurses, practical changes, and desired outcomes. Planning the training and education of nurses would provide them with detailed instructions on properly administering the medication in question. Changes should also be made to procedures already in place where applicable to further reduce errors (Trakulsunti et al., 2021). Examples could include adjusting critical expectation points for checking prescriptions, or increasing nurse double checks on each dose given throughout shifts. Focusing on reducing the occurrence of wrong dosage administration by utilizing these strategies can then lead to improved patient safety outcomes. Once developed, the plan will have a rough timeline that will detail expected outcomes and the time frame needed for successful completion. These steps could potentially help nurses provide better quality care and reduce any potential risk from errors occurring. With such an improvement plan implemented, it is an achievable goal that medication error rates may improve as a result.

Developing a viable plan for safe medication administration requires evidence-based research to support any changes in the process. The goals of the plan should be to create an environment that supports the prevention of errors and provides an infrastructure to enable learning and development for continued optimization of safety and quality initiatives (Rodziewicz & Hipskind, 2020). This can be achieved through a review of current literature on best practices as well as exploring professional resources for organizations such as the American Society of Health Systems Pharmacists (ASHP) to provide guidelines and applicable research from experienced professionals in the healthcare industry who have knowledge in this area. The evidence gathered should then be applied practically with measurable, outcome-driven objectives. This will allow the implemented plan to prevent further errors from happening by focusing on process improvement rather than fault or blame within entities or individuals involved with medication administration (Morrison et al., 2019). As such, it is important to track safety data through root cause analysis to see if the change has made an impact, as well as assess any influencing factors that may affect its efficacy such as workloads and staff capacity. Overall, such a plan can then be applied universally while being evaluated continuously under an umbrella of patient safety resources and procedures.

Available Organziational Resources

When creating a safety improvement plan to reduce medication errors, it is essential to assess existing organizational resources such as technology and specialized personnel. These available resources can ensure the successful implementation of training and education for the nurses involved (Blignaut et al., 2017). Technology, such as electronic health records, plays a major role in keeping comprehensive medical information on patients, reducing communication lags between providers, and increasing accuracy when distributing medications. Additionally, specialized personnel such as pharmacists can provide valuable insight into medication protocols and drug interactions (Rodziewicz & Hipskind, 2020). Prioritizing how resources are used according to impact on outcomes involves judging factors like cost-effectiveness, improvements that could be made with limited resources, and the immediacy of results needed. By harnessing these crucial organization assets in order to reduce medication errors, it will ultimately lead to improved patient outcomes.

Conclusion

An effective improvement plan for reducing medication errors should incorporate key components. First, it should include ways to measure accurate and precise instruction when medications are prescribed, ordered, administered, and dispensed. Second, the plan should involve measures to improve communication between healthcare providers in order to ensure that medications are delivered safely. Third, it should include feedback loops to provide the necessary information so corrective actions can be taken in a timely fashion. To evaluate whether the plan is successful, stakeholders should consider patient satisfaction surveys, nurses’ reports of wrong dosage administration, and analysis of errors at points where a medication moves through the healthcare system. Leveraging existing resources such as technology or specialized personnel can greatly enhance the improvement plan by providing support and structure for maintaining safe practices. A well-executed improvement plan for medication errors is essential for promoting patient safety and ensuring quality care.

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Question Description
I need an explanation for this Nursing question to help me study.

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.

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

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 [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

Root-Cause Analysis and Safety Improvement Plan

Irrespective of health conditions, all patients deserve high-quality care. Such care is achieved in safe care settings free from adverse events. Although health care organizations apply different strategies to optimize patient safety, adverse events that risk patients’ health still occur. A multicenter study by the World Health Organization (WHO) revealed that approximately 51% of patients admitted to Intensive Care Units (ICUs) develop healthcare-associated infections (HAIs), denoting a significant gap between the achieved and desired health outcomes (Haque et al., 2019). Broadly, root-cause analysis (RCA) evaluates the causes of such high-risk events to establish preventive measures. Therefore, the purpose of this RCA paper is to evaluate the causes of HAIs and develop a safety improvement plan.

Analysis of the Root Cause

HAIs are a significant health risk whose detection and prevention should be prioritized in health care settings. Haque et al. (2020) found that a lack of proper infection control and prevention strategies is a leading cause of HAIs in ICUs and other high-risk areas. Patients are affected differently depending on their health condition and the intensity of care needed. For instance, the risk for HAIs is high among patients using invasive devices, advanced in age, and with comorbidities (Cristina et al., 2021; Despotovic et al., 2020). Internally, nursing professionals detect HAIs as patients develop an issue not related to their condition within 48 hours. The impacts are profound since HAIs affect patients, nursing professionals, and care facilities. Among patients, HAIs increase the risk of other infections besides prolonging hospital rates and health management costs (Peters et al., 2022). As a major source of morbidity and mortality, HAIs ruin patient-provider relationships.

HAIs in ICUs and other areas due to inappropriate infection prevention and control programs denote infective response to human and technical components of environmental hygiene. According to Peters et al. (2022), the rates of HAIs are high in care facilities where environmental hygiene measures do not meet the desired standards. The technical component includes cleaning and disinfection of surfaces and devices, while the human component includes best practice implementation. Awareness of these issues is a foundation of effective control since care providers understand the source and magnitude of risk to formulate the desired response.

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.

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.

You must proofread your paper. But do not strictly rely on your computer’s

Assignment: Root Cause Analysis and Safety Improvement Plan Report

Assignment: Root Cause Analysis and Safety Improvement Plan Report

Root-Cause Analysis and Safety Improvement Plan