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

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.

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. Root-Cause Analysis and Safety Improvement Plan

Professional Context Root-Cause Analysis and Safety Improvement Plan

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.

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Instructions Root-Cause Analysis and Safety Improvement Plan

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. Root-Cause Analysis and Safety Improvement 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.

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. Root-Cause Analysis and Safety Improvement Plan
• 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 Root-Cause Analysis and Safety Improvement Plan

• 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.

TEMPLATE Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan
Your Name
School of Nursing and Health Sciences, Capella University
NURS4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year

2. Root-Cause Analysis and Safety Improvement Plan

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: Root-Cause Analysis and Safety Improvement Plan
• 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?

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3. 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. Root-Cause Analysis and Safety Improvement Plan
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 Root-Cause Analysis and Safety Improvement Plan
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.

4. Consider what existing resources may be leveraged to enhance the improvement
plan?

Conclusion

5 References
Reference page should be double spaced throughout without extra spaces between entries.
Each reference page entry should be formatted according to APA 7 guidelines with a hanging
indent as is seen here.