For this assessment, you must use the supplied template to conduct a root-cause analysis. The completed assessment will be the template, focusing on the spe

For this assessment, you must use the supplied template to conduct a root-cause analysis. The completed assessment will be the template, focusing on the specific safety concern identified in your previous assessment.

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Introduction

As patient safety concerns continue to be addressed in healthcare 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 healthcare 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.

Overview

Nursing practice is governed by healthcare 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.

For this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.

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 healthcare setting. You will create a plan to improve the safety of patients related to  the safety quality issue presented in your Assessment Supplement PDF in Assessment 1. Based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen healthcare setting, provide a rationale for your plan.

Use the  Root-Cause Analysis and Safety Improvement Plan [DOCX]  template to complete the assessment.

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 in an organization.

· Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.

· Create a viable, evidence-based safety improvement plan.

· Identify existing organizational resources that could be leveraged to improve your plan.

· Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

· Length of submission: Use the provided template to create a root-cause analysis and safety improvement plan. There is no page limit. A title page is not required but you must include a reference list as per the template.

· 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. Use the  BSN Nursing Program Library Guide  as needed.

· APA formatting: Format references and citations according to current APA style. See the  APA Module .

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide 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.

· Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.

· Competency 2: Analyze factors that lead to patient safety risks.

· Analyze the root cause of a specific sentinel event or a patient safety issue in an organization.

· Competency 3: Identify organizational interventions to promote patient safety.

· Identify existing organizational resources that could be leveraged to improve a plan.

· Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

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Criterion 1

Analyze the root cause of a specific sentinel event or a patient safety issue in an organization.

Distinguished

Analyzes the root cause of a specific sentinel event or a patient safety issue in an organization. Notes the degree to which various causes contributed to the issue or event.

Proficient

Analyzes the root cause of a specific sentinel event or a patient safety issue in an organization.

Basic

Identifies the root cause of a specific sentinel event or a patient safety issue in an organization.

Non Performance

Does not identify the root cause of a specific sentinel event or a patient safety issue in an organization.

Criterion 2

Apply evidence-based and best-practice strategies to address a safety issue or sentinel event.

Distinguished

Applies evidence-based and best-practice strategies to address a safety issue or sentinel event. Notes how the strategies will address the issue or event.

Proficient

Applies evidence-based and best-practice strategies to address a safety issue or sentinel event.

Basic

Describes evidence-based and best-practice strategies, but their relevance to the safety issue or sentinel event is unclear.

Non Performance

Does not apply evidence-based and best-practice strategies to address a safety issue or sentinel event.

Criterion 3

Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.

Distinguished

Creates a feasible, evidence-based safety improvement plan. Refers explicitly to scholarly or professional resources to support the plan.

Proficient

Creates a feasible, evidence-based safety improvement plan.

Basic

Creates a safety improvement plan that lacks sufficient evidence or may not be feasible.

Non Performance

Does not create a safety improvement plan.

Criterion 4

Identify existing organizational resources that could be leveraged to improve a plan.

Distinguished

Identifies existing organizational resources that could be leveraged to improve a plan. Prioritizes resources according to potential impact.

Proficient

Identifies existing organizational resources that could be leveraged to improve a plan.

Basic

Identifies existing organizational resources, but their relevance to the plan is unclear.

Non Performance

Does not identify existing organizational resources that could be leveraged to improve a plan.

Criterion 5

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

Distinguished

Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar and punctuation, and word choice, and is free of spelling errors.

Proficient

Organizes content so ideas flow logically with smooth transitions; content contains few errors in grammar or punctuation, word choice, and spelling.

Basic

Organizes content with some logical flow and smooth transitions. Content contains errors in grammar or punctuation, word choice, and spelling.

Non Performance

Does not organize content for ideas. Content lacks logical flow and smooth transitions.

Criterion 6

Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Distinguished

Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

Proficient

Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Basic

Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.

Non Performance

Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.

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Remove or Replace: Header Is Not Doc Title

Root-Cause Analysis and Safety Improvement Plan

Completed by: (Student Name)

Organization: School of Nursing and Health Sciences, Capella University

Department: NURS4035: Improving Quality of Care and Patient Safety

Reported to: (Instructor Name)

Date Completed by: (Date)

This template is provided as an aid in organizing the steps in a root-cause analysis. Not all possibilities and questions will apply in every case, and there may be others that will emerge in the course of the analysis. However, all possibilities and questions should be fully considered in your quest for “root cause” and risk reduction.

A sentinel event is a  patient safety event  that occurs unexpectedly  and is not primarily related to the natural course of the patient’s illness or underlying condition.

These events are  debilitating not only for patients but also for the health care providers involved. The goal is to learn from these incidents, improve systems, and prevent further harm to patients

Remember, a thorough root-cause analysis aims to uncover both immediate causes and underlying systemic issues to prevent similar events in the future.

Understanding What Happened
1. What happened?: Begin by understanding the  sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the  timeline,  people involved, and  context. · Who did the problem/event affect, and how?
2. Why did it happen?: · Human Factors: Investigate whether  communication breakdowns,  staff fatigue, or  lack of training contributed. · System Factors: Examine  workflow processes,  equipment failures, and  environmental factors. · Organizational Culture: Assess if there are  cultural issues,  lack of safety culture, or  inadequate leadership support. · Society/Culture: What role might cultural assumptions or backgrounds play?
3. Was there a deviation from protocols or standards?: · Procedures and Policies: Determine if established  protocols were followed or if there were deviations. · Were there any steps that were not taken or did not happen as intended? · Documentation: Review  medical records,  nursing notes, and other relevant documentation.
4. Who was involved?: · Staff: Identify the  roles of individuals directly involved in the event. · Supervisors and Managers: Investigate
5. Was there a breakdown in communication?: · Interdisciplinary Communication: Assess how well different teams communicated. · Patient-Provider Communication: Explore whether patients were informed and understood their care.
6. What were the contributing factors?: · Physical Environment: Consider  facility layout,  equipment availability, and  workspaces. · Staffing Levels: Evaluate if staffing was adequate. 7. Training and Competency: Assess staff’s  knowledge and  skills.
8. Did organizational policies or procedures play a role?: · Policy Compliance: Investigate if policies were followed. · Policy Clarity: Assess if policies are  clear and  accessible.
9. Was there a failure in monitoring or surveillance?: · Vital Signs Monitoring: Check if there were any missed signs. · Alarm Fatigue: Explore if alarms were ignored.
10. What can be learned to prevent recurrence?: · Lessons Learned: Identify  systemic changes,  training needs, and  improvement opportunities. · Quality Improvement: Consider implementing  preventive measures.
11. How can patient safety be enhanced?: · Risk Mitigation: Develop strategies to  minimize risks. · Education and Training: Ensure staff are well-trained. 12. Reporting and Feedback: Encourage open reporting and learning from mistakes.

Root Cause(s) to the issue or sentinel event?

Upon completion of the analysis above, please explicitly state one or more root causes that led to the issue or sentinel event. Please refer to the factors discussed above and categorize each root cause by choosing all that apply.

Root Cause – the most basic reason that the situation occurred		Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal	HFC	HF T	HF F/S	E	R	B
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	2
	3

HF-C = Human Factor-communication HF-T = Human Factor-training HF-F/S = Human Factor-fatigue/scheduling

E= environment/equipment R= rules/policies/procedures B=barriers

Application of Evidence-Based Strategies

Identify evidence-based best practice strategies to address the safety issue or sentinel event.

(Describe what the literature states about the factors that lead to the safety issue) (For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.)

Explain how the strategies could be applied in the safety issue s or sentinel events you have identified.

Safety Improvement Plan

List any future actions needed to prevent reoccurrence.

Action Plan One for each Root Cause/Contributing Factor from above	E / C / A Choose one
1
2
3

E = eliminate (i.e. piece of equip is removed, fixed or replaced.)

C = control (i.e. additional step/warning is added or staff is educated/re-educated)

A = accept (i.e. formal or informal discussions of “don’t let it happen again” or “pay better attention” but nothing else will change and the risk is accepted)

Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).

Provide a description of the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.

The post For this assessment, you must use the supplied template to conduct a root-cause analysis. The completed assessment will be the template, focusing on the spe first appeared on Nursing Worker.