NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Assessment 2 Root Cause Analysis and Safety Improvement Plan

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Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

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Root-Cause Analysis and Safety Improvement Plan

Root Cause Analysis (RCA) serves as a vital method for identifying factors contributing to patient safety risks. Given the significant occurrence of medication administration issues and adverse events in healthcare organizations, patient safety has emerged as a critical concern. RCA plays a pivotal role in reducing preventable adverse events, enhancing patient safety measures, and fostering learning and quality improvement in healthcare settings. Notably, medication errors, including medication administration errors (MAEs), rank among the leading causes of patient safety risks, with studies indicating their prevalence and impact on patient outcomes (Samsiah et al., 2020). This review focuses on analyzing the root causes of drug administration errors in the diabetic ward, with an emphasis on evidence-based safety improvement strategies and organizational interventions to promote patient safety.

Analysis of the Root Cause

Multiple factors contribute to medication administration errors in the diabetes ward. These include inadequate training, deviation from medication administration guidelines, lack of experience, interruptions during medication administration, communication failures, insufficient knowledge, and various human factors. Studies have shown a positive correlation between nursing staff experience and the quality of patient care, underscoring the importance of ongoing training and education (Ulrich et al., 2022). Additionally, communication gaps among healthcare professionals and lack of medication knowledge have been identified as significant contributors to MAEs (Schroers et al., 2020). Deviation from guidelines and interruptions during medication administration also elevate the risk of errors (Wondmieneh et al., 2020). Human factors such as work stress and errors in prescription writing further compound the issue (Brigitta & Dhamanti, 2020).

Application of Evidence-Based Strategies

To mitigate medication administration errors, evidence-based strategies are imperative. Training and education of nursing staff have been shown to enhance patient safety by improving medication accuracy and adherence to the “five rights” of medication administration (Yoon & Sohng, 2021). Technological solutions such as Barcode Medication Administration (BCMA) systems and Clinical Decision Support (CDS) systems offer additional safeguards by reducing errors related to misidentification and providing decision support during drug administration (FitzHenry et al., 2020; Melton et al., 2019). Implementing a culture of safety that encourages open communication and non-punitive error reporting is also essential (Shah et al., 2022).

Evidence-Based Safety Improvement Plans

Safety improvement plans should incorporate root cause analysis findings and evidence-based interventions. Establishing a blame-free culture encourages error reporting, facilitating timely interventions and prevention of adverse events (Carver & Hipskind, 2019). Collaborative efforts between nurses and physicians, along with the use of technological tools and methodologies like Lean Six Sigma, can streamline processes and reduce errors (McDermott et al., 2022). Furthermore, leveraging organizational resources, including healthcare staff, technology, and financial resources, is crucial for successful implementation of safety improvement initiatives.

Conclusion

Root cause analysis provides a systematic approach to understanding and addressing medication errors, thereby enhancing patient safety in healthcare settings. Evidence-based strategies, coupled with organizational resources and a culture of safety, are essential for effectively mitigating medication administration errors and improving patient outcomes.

References

Carver, N., & Hipskind, J. E. (2019, April 28). Medical Error. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430763/ FitzHenry, F., Eden, S. K., Denton, J., Cao, H., Cao, A., Reeves, R., Chen, G., Gobbel, G., Wells, N., & Matheny, M. E. (2020). Prevalence and risk factors for opioid-induced constipation in an older national Veteran cohort. Pain Research and Management, 2020, 1–11. https://doi.org/10.1155/2020/5165682 McDermott, O., Antony, J., Bhat, S., Jayaraman, R., Rosa, A., Marolla, G., & Parida, R. (2022). Lean six sigma in healthcare: A systematic literature review on motivations and benefits. Processes, 10(10), 1910. https://doi.org/10.3390/pr10101910 Melton, K. R., Timmons, K., Walsh, K. E., Meinzen-Derr, J. K., & Kirkendall, E. (2019). Smart pumps improve medication safety but increase alert burden in neonatal care. BMC Medical Informatics and Decision Making, 19(1). https://doi.org/10.1186/s12911-019-0945-2 Samsiah, A., Othman, N., Jamshed, S., & Hassali, M. A. (2020). Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics. International Journal of Clinical Pharmacy, 42(4), 1118–1127. https://doi.org/10.1007/s11096-020-01041-0

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1). https://doi.org/10.1016/j.jcjq.2020.09.010 Shah, F., Falconer, E. A., & Cimiotti, J. P. (2022). Does root cause analysis improve patient safety? A systematic review at the department of veterans affairs. Quality Management in Health Care, Publish Ahead of Print. https://doi.org/10.1097/qmh.0000000000000344 Ulrich, B., Cassidy, L., Barden, C., Varn-Davis, N., & Delgado, S. A. (2022). National Nurse Work Environments – October 2021: A Status Report. Critical Care Nurse, 42(5), e1–e18. https://doi.org/10.4037/ccn2022798 Visvalingam, P. A. A., Hamid, S. B. A., Basha, M. A. B. M. K., & Atan, A. (2023). A systematic review of knowledge, attitude, practice and the associated factors of medication error among registered nurses. IJFMR – International Journal for Multidisciplinary Research, 5(4). https://doi.org/10.36948/ijfmr.2023.v05i04.4202

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0 Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic reporting system. Nursing Open. https://doi.org/10.1002/nop2.1038

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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. NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

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I discourage over-utilization of direct quotes in DQs and assignments at the Master’s 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.

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For assignments that need to be submitted to Lopes Write, 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 Loud-cloud for tips on improving your paper and SI score.

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The university’s policy on late assignments is a 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. NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

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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.

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