Root-Cause Analysis and Safety Improvement Plan

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

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 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.

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.

Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course.

SCORING GUIDE

Use the scoring guide to understand how your assessment will be evaluate

Resources: Evidence-Based Practice

Evidence-Based Practice

Giomuso, C. B., Jones, L. M., Long, D., Chandler, T., Kresevic, D., Pulphus, D., & Williams, T. (2014). A successful approach to implementing evidence-based practice. Med-Surg Matters, 23(4), 4–9.

This article provides a baseline definition of evidence-based practice as well as examples of implementing EBP in practice.

Spruce, L. (2015). Back to basics: Implementing evidence-based practice. AORN Journal: The Official Voice of Perioperative Nursing, 101(1), 106–114.

This article provides a framework for identifying and appraising research, as well as implementing changes and practices based on research.

Quality and Safety

Root-Cause Analysis

Sentinel Events

Safety and Sentinel Event Case Studies


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