Phillip April 18, 2024 No Comments

Root Cause Analysis and Safety Improvement Plan

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety Prof. Name Date 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

Phillip September 15, 2023 No Comments

NURS FPX 4020 Assessment 4 – Improvement Plan Tool Kit 

NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit  Student Name Capella University NURS-FPX 4020: Improving Quality of Care and Patient Safety Prof. Name Date Improvement Plan Tool Kit A safety improvement plan requires a handful of information that can be disseminated among the concerned group of people. In healthcare settings, all the information that is gathered for preparing a safety improvement plan is distributed among healthcare professionals, administrators, leaders, and other allied professionals connected with the healthcare facilities. This communication includes information from authentic, credible, and relevant evidence-based resources so that a justified safety improvement plan is implemented. In this assessment, an improvement plan tool kit is developed on medication administration errors (MAEs). The databases used to develop this tool kit are; Google Scholar, PubMed Central, Capella Online Library, CINAHL, ScienceDirect, and JSTOR. The purpose of this resource tool kit is to assist nurses and nurse leaders to implement the medication safety improvement plan with profound knowledge and understanding of the related concepts for achieving successful outcomes.  Resource Tool Kit – Implementation and Sustainability  This resource kit is categorized into four easy-to-understand categories which will help nurses and nurse leaders to specifically take assistance from the source which is related to the particular concern. These categories are; a) risk factors of medication administration errors, b) nurses’ and nurse managers’ role in medication safety, c) medication error reporting, and d) evidence-based solutions for improving medication safety.  Risk Factors of MAEs Assunção-Costa, L., de Sousa, I. C., Silva, R. K., do Vale, A. C., Pinto, C. R., Machado, J. F., Valli, C. G., & de Souza, L. E. (2022). Observational study on medication administration errors at a University Hospital in Brazil: Incidence, nature, and associated factors. Journal of Pharmaceutical Policy and Practice, 15(1). https://doi.org/10.1186/s40545-022-00443-x  This resource used a prospective observational method to determine the incidence, and nature and identify the factors associated with medication administration errors. The professionals who undertook this study claimed that 36.2% of MAEs were observed in University Hospitals. Some of the factors identified through the study are interruptions, excessive workload, and errors in the route of administration. Moreover, the highest risk of MAEs was found in intravenous medications. Since medication administration errors are very common in healthcare practices, this study is useful for nurses and nurse leaders to enhance their knowledge about factors that can lead to medication administration errors. Knowledge of these factors with help them in identifying similar aspects in their hospitals and implement safety improvement plans accordingly to make achievable and sustainable reforms. Furthermore, IV medications can become life-threatening for patients if are wrongly administered. Thus, this resource assists healthcare professionals and their leaders to make constant efforts to improve the quality of care and ensure patients’ safety is a priority.  Rostami, P., Heal, C., Harrison, A., Parry, G., Ashcroft, D. M., & Tully, M. P. (2019). Prevalence, nature and risk factors for medication administration omissions in English NHS Hospital Inpatients: A retrospective multicentre study using medication safety thermometer data. BMJ Open, 9(6). https://doi.org/10.1136/bmjopen-2018-028170  In the study by Rostami and colleagues (2019), Medication Safety Thermometer Data was utilized to conduct a retrospective study to determine the prevalence, and risk factors related to specifically omission medication errors. Omission errors are defined as a lack of administration of a medicine or a dose (missed administration). The study revealed that medication omission errors are highly prevalent in hospitalized patients. One of the predictors of these errors is the high number of prescribed medications which led nurses to miss a dose of medicine during administration. Other factors that lead to these errors are refusals from patients, unavailability of drugs, and clinical reasons which may prevent medicines to be given. This study is aimed at preparing healthcare professionals especially nurses to identify the high-risk population who might experience omission errors and establish particular strategies to overcome these errors. NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit . This resource is helpful for nurses as the risk factors (patient refusal and unavailability of drugs) are very common issues faced in hospitals worldwide. In terms of patient refusal, patients must be informed about risks and benefits to ensure patient safety is maintained. Omission errors can also be due to excessive workload because of the high number of medicines. Thus, administrators of a hospital should take immediate action to eradicate these errors from the hospital as a 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(1). https://doi.org/10.1186/s12912-020-0397-0  This study is conducted in Ethiopia to examine the extent of medication administration errors and identify the causative factors which lead nurses to commit these errors. Lack of training and education, lack of experience, absence of standardized guidelines, and constant disruptions during administration and night shift duty were some of the associated factors recognized in this study. This study is useful for nurses and nurse leaders for example, they can identify some of these or other contributing factors in their workplaces using root-cause analysis which will further help them in modifying the safety improvement plan based on these factors. Furthermore, the study also recommends some the strategies like continuous educational training, preparation of standardized guidelines and making them available for nurses, creating a supportive and safe environment for nurses to administer drugs, and retaining experienced nurses for medication administration. The methods will assist nurses to provide quality care, reduce safety risks in terms of medication and improve patients’ satisfaction levels.   Role of Nurses and Managers in Medication Safety Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences, 1(1), 26–41. https://doi.org/10.21608/ejnhs.2020.80266  This article is aimed at describing the factors that contribute to medication errors specifically related to nurses and recommends the intervention that can be done by nurse managers to prevent these errors. It explains that nurses are the last line of safety in the medication process thus they are responsible to identify these factors so that errors

Phillip September 15, 2023 No Comments

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

NURS FPX 4020 Assessment 2- Root Cause Analysis and Safety Improvement Plan Student Name University Name NURS FPX 4020 Improving Quality of Care and Patient Safety Instructor Name Date   Root-Cause Analysis and Safety Improvement Plan Root Cause Analysis (RCA) is an efficient approach to determine the factors pertaining to patient safety risks. Because of a high incidence of medication administration issues and adverse events in the healthcare organization patient safety has gathered immense attention and has been found to be of paramount importance. RCA has an important role in reducing preventable adverse events improving patient safety measures, and improving learning and quality in healthcare settings. Medication errors account for the eighth leading cause of death in the USA. Medication errors, particularly medication administration errors are leading factors contributing to patient safety risks. A number of studies have reported that MAEs are among the most common medical errors to occur in acute care settings as well, leading to an extended hospital stay (Samsiah et al., 2020). This review is particularly aimed at analyzing the root causes of drug administration errors causing patient safety issues in the diabetic ward. In this analysis, patient safety issues or sentinel events pertaining to medication administration will be discussed, with the main focus on evidence-based safety improvement strategies and organizational interventions that could be used to promote patient safety Analysis of the Root Cause Various factors can be attributed to being the root cause of medication administration error to Mr. Wallace in the diabetes ward. The potential root causes of medication administration error discussed in Assessment 1 include the lack of adequate training, deviation from guidelines for medication administration, inadequate work experience, interruption during medication administration, inefficient communication, lack of sufficient knowledge, and some human factors leading to errors pertaining to patient safety issues.  Nursing staff with inadequate training make mistakes more often than the nurses who regularly receive training on nursing practices and pharmaceutical knowledge. A study depicted a positive correlation between the experience of nursing staff and the quality of patient care administered by them (Ulrich et al., 2022). Lack of communication between the nurses, clinicians, and other colleagues in the healthcare setting often results in medication administration errors by the nurses.  A qualitative evaluation done to provide qualitative evidence of nurses’ reported causes of MAEs, suggested lack of medication knowledge to be the predominant knowledge-based issue (Schroers et al., 2020). The unavailability of appropriate guidelines and deviation from medication administration guidelines increases the risk of MEs done by nurses up to twofold (Wondmieneh et al., 2020). MAEs can be prevented by minimizing interruptions during the medication administration process. Human error due to work stress, errors in prescription writing or transcribing, and lack of work experience, etc. contribute to about 19.4% of MAEs (Brigitta & Dhamanti, 2020). Application of Evidence-Based Strategies To address the obstacles that contribute to safety issues related to medication administration errors in hospitalized patients, evidence-based solutions are necessary to establish a safety culture and improve nurses’ competence. Since nurses are the key personnel in establishing accurate medication lists, detecting anomalies, and preventing mistakes caused by drug interactions or omissions, training and education of nurses have a positive impact on the reduction of medication administration errors (Yoon & Sohng, 2021). Nurses can enhance the accuracy of drug history and prevent adverse events by actively involving patients, their families, and other healthcare providers in the process. The majority of the errors of the drug administration stage can be avoided by nurses during drug administration to the patient by ensuring the “five rights” (the right patient, the right drug, the right dose, the right route, and the right time) of pharmaceutical administration. The BCMA System has also shown considerable benefits in terms of reducing the likelihood of administrative mistakes due to misidentification or miscommunication (FitzHenry et al., 2020). The use of a Barcode Medicine Administration (BCMA) system also aids in the confirmation of these “five rights” of medicine administration.  The use of smart infusion pumps with Dose Error Reduction Systems (DERS) is a successful approach for reducing intravenous drug delivery mistakes (Melton et al., 2019). Clinical Decision Support (CDS) Systems are cognitive tools that help nurses make educated judgments during drug administration. Independent double-checks for high-risk medications, aid in risk mitigation, and provide additional safety precautions during administration. It is critical to foster a culture of safety and open communication for nurses to disclose errors and near-misses without fear of retaliation. Organizations should set up non-punitive reporting procedures to uncover system flaws so that the root causes of errors can be analyzed and addressed.  Evidence-Based Safety Improvement Plans Safety improvement plans are developed with the purpose of reducing errors leading to adverse events. These plans include the systematic incorporation of root cause and error-based multiple-solution strategies. Establishing a blame-free culture where the main focus relies on the causes of errors and not on the human responsible for the error, can result in subsequent reporting of medication administration errors thus leading to timely interventions and prevention of morbidities (Carver & Hipskind, 2019). Effective communication and collaboration between nurses and physicians have been found to have a positive impact on the quality of patient care provided in hospitals (Visvalingam et al., 2023). Root-Cause Analysis and Safety Improvement Plan The implementation of technological tools such as BCMA and CDSS effectively aid in delivering accurate medication administration by streamlining the process of medication administration and maintaining accurate patient record.  The methodology of Lean Six Sigma Plus has been used extensively in hospitals with the aim of reducing medication errors. LSS uses the combined processes of Lean and Six Sigma to reduce the wastage of resources and identification of defects and variabilities. LSS can be particularly helpful in streamlining the processes and reducing medical errors. It works by standardizing the protocols and enhancing patient satisfaction (McDermott et al., 2022). Organizational Resources To get the maximum impact of a comprehensive safety improvement plan, existing and potential organizational resources must be optimally used. Organizational resources at the hospital

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