Root-Cause Analysis and Safety Improvement Plan
School of Nursing and Health Sciences, Capella University
NURS4020: Improving Quality of Care and Patient Safety
Root-Cause Analysis and Safety Improvement Plan
Different events occur in the nursing profession, and if an error occurs in the medical administration, it will be a significant issue. It is essential for the nurses to consider the medication errors and to observe whether they are giving the proper medication to the patient. Last week, a mistake in medical administration occurred, and it was the worse situation. The senior nurse was on duty and the junior nurse signed off by completing her shift. One of the patients suffered from high blood pressure and hypertension and started vomiting. The patient was bitterly vomiting while he was on high fever, and there was no issue of nausea and vomiting since his admission to the hospital.
Analysis of the Root Cause
The event has already been explained that a patient started vomiting in the hospital, and it was continuous vomiting. The patient was o high-grade fever, and there was no link to vomiting with the patient. The junior hospital assistant detected the problem and called the senior nurse to the duty, and it was a moment of tension for the patient and his family. The nurses noticed that the wrong medication caused the problem. Acetaminophen is the patient’s allergic drug, and the junior nurse did not tell the senior nurse of the patient’s allergy. The nurses’ negligence led the patient to face the issue.
It was supposed to happen that the senior nurses needed to ask about all the patients and their conditions. The junior nurse had to inform the old nurse of the patient’s allergy. The environmental factors could not play an essential role because no one was in the patient’s room. The resource factors or equipment did not have any influence. Human errors and communication played a crucial role in the patient’s situation because it was found that the wrong administration of medication caused the issue.
Application of Evidence-Based Strategies
There are many strategies to address the wrong medication. The nurse should update the incidence reporting system to ensure that the patients, their families, or the hospital staff must inform the relevant doctors or nurses of the issue. It was impossible to address the incidence reporting issue in the current event because the error had already occurred. It was important for the nurse to remove the IV because the medicine was given through the route. The patient was given the medication to overcome nausea and vomiting. The patient was given saline water (Sonğur, 2018).
Several other strategies can overcome the wrong medication, including effective communication and coordination. Most of the cases have observed that the medication errors are because by human errors and mistakes. The nurses could not communicate with one another effectively.
In the current scenario, the senior and junior nurses did not have the proper communication because the errors occurred. It was important for the hospital administration to encourage the nurses to communicate thoroughly before leaving. The nurses should read the prescription paper before giving any medication to the patient.
The literature is full of such incidents and the strategies where the communication strategies were ineffective and the nurses could not manage. The nurses need to communicate well and ensure the patients’ proper medication. If the patients are not given the appropriate medication, there will be negative consequences on health. So, the right medication is necessary.
Improvement Plan with Evidence-Based and Best-Practice Strategies
Some different strategies and policies are used to address the wrong medication. Medication errors have become a common debate in the literature, and the nurses are found to be responsible for them. Most of the time, the nurses do not communicate properly with their colleagues and cannot handle the matter. The wrong medication is primarily the result of miscommunication and an inefficient reporting system. The wrong medication can be addressed through different strategies. These strategies are national or international level, and it is seen that the medical errors are almost similar (Klingbeil, 2018).
The first strategy or the policy of wrong medication is the right person, the proper medication, and the correct dose. The exemplary method and right timeline are also included in the strategy and policy. The nurses need to ask one another, or if the relevant nurse is not available, it is good to consult the doctor before the medication. If the proper medication is not given, the situation can be worse. The correct patient and right dose are essential because the right dose is necessary. Otherwise, the worse consequences can occur. The nurses need to improve the reporting incidence system in the hospital as well.
If we analyze the current scenario, it can easily be seen from the situation that the nurses have miscommunication, and it was a human error. The hospital should initiate the new policies for the nurses and other staff members to ensure proper communication and help the patients recover as early as possible. one of the most important things that the nurses have to improve is the incidence reporting system. The proper training will enhance the incidence reporting system (Hong, 2019).
The training will help the patients and the nurses to have care coordination. The medical errors will be reduced, and the communication gap will be minimized. All these strategies will help in the better results.
Existing Organizational Resources
The initiative should be taken to improve the communication among the nurses, and it is essential to reduce medical errors. The nurses are usually involved in medical errors, and it is observed that different existing and new resources are needed to accomplish the plan. The plan will be implemented within two months. Additional steps are required for the organization, which will help improve the medication error (Härkänen, 2018).
The existing resources are the laptops and computers that will integrate the technology with the patients. The nurses will have to compile the records of patients on the computer so the coming nurses may see the data. There should be an incidence reporting system already linked with the software. So, there is no need for more resources, but the existing resources will be enough. Moreover, it is essential to improve the nurses’ communication skills, and the training sessions will be arranged for them. Communication is the strength of the hospital organization because the nurses will better understand one another, and the medication errors will be reduced (Costa, 2021).
In conclusion, it is seen that medical errors are most common in hospitals, and they involve the nurses. Nurses need to overcome the issues of medical errors. Different strategies will be overcome through the various methods and policies discussed above. All the plans will be helpful and will be better for the hospital administration in the future.
Costa, C. R. D. B., Santos, S. S. D., Godoy, S. D., Alves, L. M. M., Silva, Í. R., & Mendes, I. A. C. (2021). Strategies For Reducing Medication Errors During Hospitalization: Integrative Review. Cogitare Enfermagem, 26. https://doi.org/10.5380/ce.v26i0.79446.
Härkänen, M., Blignaut, A., & Vehviläinen‐Julkunen, K. (2018). Focus group discussions of registered nurses’ perceptions of challenges in the medication administration process. Nursing & Health Sciences, 20(4), 431-437. https://doi.org/10.1111/nhs.12432.
Hong, K., Hong, Y. D., & Cooke, C. E. (2019). Medication errors in community pharmacies: The need for commitment, transparency, and research. Research in Social and Administrative Pharmacy, 15(7), 823-826. https://doi.org/10.1016/j.sapharm.2018.11.014.
Klingbeil, C., & Gibson, C. (2018). The teach-back project: a system-wide evidence-based practice implementation. Journal of Pediatric Nursing, 42, 81-85. https://doi.org/10.1016/j.pedn.2018.06.002
Sonğur, C., Özer, Ö., Gün, Ç., & Top, M. (2018). Patient safety culture, evidence-based practice, and performance in nursing. Systemic practice and action research, 31(4), 359-374. https://doi.org/10.1007/s11213-017-9430-y.
Assessment 3 Instructions: Improvement Plan In-Service Presentation
Top of Form
Bottom of Form
· For this assessment, you will develop an 8 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.
As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.
The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).
As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.
You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.
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.
1. Explain the need and process to improve safety outcomes related to medication administration.
1. Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
. Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
2. List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
2. Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
3. Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
3. Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursingâ€‹, 47(3), s16–s17.
As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.
For this assessment it is suggested you take one of two approaches:
· Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or
· Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.
The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.
Be sure that your presentation 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.
· List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
· Explain the need for and process to improve safety outcomes related to medication administration.
· Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
· Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
· Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.
There are various ways to structure an in-service session; below is just one example:
· Part 1: Agenda and Outcomes.
. Explain to your audience what they are going to learn or do, and what they are expected to take away.
· Part 2: Safety Improvement Plan.
. Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
. Explain why it is important for the organization to address the current situation.
· Part 3: Audience’s Role and Importance.
. Discuss how the staff audience will be expected to help implement and drive the improvement plan.
. Explain why they are critical to the success of the improvement plan focusing on medication administration.
. Describe how their work could benefit from embracing their role in the plan.
· Part 4: New Process and Skills Practice.
. Explain new processes or skills.
. Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
. In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
· Part 5: Soliciting Feedback.
. Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
. Explain how you might integrate this feedback for future improvements.
Remember to account for activity and discussion time.
For tips on developing PowerPoint presentations, refer to:
· Capella University Library: PowerPoint Presentations.
· Guidelines for Effective PowerPoint Presentations [PPTX].
· Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be at least 10 slides and no more than 15 slides (not including the title, conclusion, or references slides).
· Speaker notes: Speaker notes (located under each slide) should reflect what you would actually say if you were delivering the presentation to an audience. This presentation does NOT require audio or a transcript. Another presenter would be able to use the presentation by following the speaker’s notes.
· APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
· Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.
· SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
VIEW SCORING GUIDE
Improvement Plan In-Service Presentation Scoring Guide
List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Does not list the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Lists with insufficient clarity the purpose and goals of an in-service session on safe medication administration for nurses.
Lists clearly the purpose and goals of an in-service session on safe medication administration for nurses.
Lists clearly the purpose and goals of an in-service session on safe medication administration for nurses, with purpose and goals that are relevant and achievable within the in-service session.
Explain the need and process to improve safety outcomes related to medication administration.
Does not describe the need and process to improve safety outcomes related to medication administration.
Describes a safety improvement outcome for medication administration, but the described need for the improvement or process to achieve improvement is unclear or irrelevant.
Explains the need and process to improve safety outcomes related to medication administration.
Explains the need and process to improve safety outcomes related to medication administration, with reference to specific data, evidence, or standards to support the explanation.
Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
Does not describe the audience’s role in and importance of making the improvement plan focusing on medication administration successful.
Describes the audience’s role in the improvement plan focusing on medication administration but does not clearly address how the audience is important to the success of the improvement plan.
Explains audience’s role and importance of making the improvement plan focusing on medication administration successful.
Explains audience’s role and importance of making the improvement plan focusing on medication administration successful, using persuasive and transparent communication to improve buy-in.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Does not list resources or activities related to safe medication administration.
Lists resources or activities related to safe medication administration, but their relevance to skill development or process understanding related to a safety improvement initiative is unclear.
Creates resources or activities to encourage skill development and process understanding related to a safety improve initiative on medication administration.
Creates resources or activities to encourage skill development and process understanding related to a safety improve initiative on medication administration, explaining their value.
Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
Slides are difficult to read with multiple editing errors. No speaker notes provided.
Slides are easy to read with few editing errors. Speaker notes are sufficient to support the slides.
Slides are easy to read and error free. Detailed speaker notes are provided.
Slides are easy to read and clutter free. Slide background is “visually” pleasing with a contrasting color for the text and may utilize graphics. Detailed speaker notes are provided.
Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
Does not organize content with clear purpose or goals. PowerPoint slides do not support main points, assertions, arguments, conclusions, or recommendations. Sources are not relevant or evidence-based (published within 5 years).
Organizes content with clear purpose or goals. PowerPoint slides do not consistently support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources (published within 5 years).
Organizes content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
Organizes content with clear purpose or goals. PowerPoint slides support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources (published within 5 years).
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