NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

Capella University NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan– Step-By-Step Guide

This guide will demonstrate how to complete the Capella University  NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

Whether one passes or fails an academic assignment such as the Capella University  NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan  depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan 

The introduction for the Capella University  NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan  is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

After the introduction, move into the main part of the  NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan  assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for  NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan 

Root cause analysis is an important practice in nursing that facilitates the identification and management of issues that could potentially affect the quality and safety of care given to patients. Root cause analysis provides insights into the environmental, patient, provider, or organizational factors that contribute or predispose organizations to safety and quality issues. Therefore, this paper presents a root cause analysis of medication administration error of the administration of incorrect dose of medications to patients in medical surgical units. The paper examines the issue of medication administration error pertaining to incorrect dose administration, evidence-based strategies to address it, safety improvement plan for the issue and the organizational resources that should be utilized to address the issue.  

Analysis of the Root Cause 

According to Tariq et al. (2020), the administration of incorrect dose of medications to a patient is a medication error that can affect adversely the outcomes of care. The administration of incorrect dose of medication can either be under or overdose. The administration of incorrect medication dosage has adverse impacts on health and health outcomes of patients. Accordingly, it increases the risk of adverse reaction to medications, which may worsen the health status and response to treatment by patients. The error also contributes to under-management of the health problems facing the patients. The administration of low dose of medication affects the therapeutic effectiveness of medications alongside poor response to treatment (Hammoudi et al., 2018). The consequences of the administration of incorrect dose of medications include extended hospital stay, high costs of care, development of resistant strains of disease-causing organisms and death.  

Based on the above adverse effects of the error of administration of incorrect doses of medication, a root-cause analysis was performed in 45 cases of incorrect dose administration in the medical surgical unit. The aim of the analysis was to identify the causes of incorrect administration of drug dosage and its effect on the health of the patients. A team comprising of experts that included nurse managers, physicians and quality improvement personnel undertook the process. The review of the reported incidents of incorrect dose administration of medications showed that almost half of the incidents were due to low dose administration while the remaining half was due to overdosing the patients. The analysis further showed that the majority of the incidents happened during the night shift when staff-to-patient ratio was likely to be low. In addition, the errors were found to have led to either extended hospital stay or development of minor adverse reactions by the patients.  

Evidence has shown that nurses are highly prone to administrating the wrong dose of medication in cases where distractions are high. Accordingly, up to 75% of the cases of medication administration errors are largely attributed to distractions in the clinical setting (Tariq et al., 2020). The analysis of the incidents showed that most of the incorrect doses of medications that were administered in the medical and surgical units occurred in situations where the care needs of the patients was high. According to Thomas et al., (2017), high cognitive load predisposes nurses to medication errors. The high cognitive load in nursing practice is attributed to the multiple complex cases of care that require the attention of the nurses. The risks of medication errors are enhanced significantly in cases where the staffing level of nurses is low. The analysis conducted in the medical and surgical units showed that a high proportion of medication administration errors (85%) were reported during night shifts when the staffing ratio was low. As a result, the workload for the nurses increased significantly, raising their cognitive load and predisposition to cognitive errors in medication administration (Alemu et al., 2017). The last factor that was identified from the analysis was the effect of the experience level of staffs. The statistic showed that 32% of the medication errors analyzed in the process were attributed to low experience among the staffs who committed the error. Therefore, the above findings guided the determination of an effective intervention to address the issue of incorrect dose of medication administration in the units.  

Application of Evidence-Based Strategies  

The root cause analysis showed that the most of the incorrect dose administration errors occurred during the night shift when the nurse-staffing ratio is high. As a result, it is recommended that the consideration of appropriate staffing ratio for nurses during night shifts when the care needs of patients is high to be considered. High workload predisposes nurses to burnout that affect their ability to make accurate decisions about the treatment needs of the patients (Tariq et al., 2020). Optimizing the nurse-patient ratio during night shift would therefore reduce the risk of medication error occurrence in the units.  

Interventions that minimize distractions during medication administration are also recommended to reduce and prevent the risk of medication administration errors. Accordingly, minimizing sources of distraction such as physician ward rounds should be adopted to lower the risk of medication administration errors (Tariq et al., 2020). There is also the need for proactive planning alongside team engagement to minimize the risk of medication administration errors in the medical and surgical wards. For example, the use of nursing care models such as total nursing care model can be used to ensure that patient-centered care that minimizes safety and quality issues is provided.  The provision of opportunities that promote the professional growth and development of nurses is also recommended (Latimer et al., 2017). The analysis showed that nurses would little clinical experience was prone to committing the error of incurred dose administration when compared to those with extensive clinical experience. Consequently, there is a need to provide training and educational opportunities to nurses about medication errors, types, risk factors, and preventive strategies. The provision of educational opportunities will raise the level of knowledge among the nurses about the preventive strategies for medication administration errors.  

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NURS-FPX4020 Enhancing Quality and Safety

Improvement Plan with Evidence-Based and Best-Practice Strategies 

The proposed improvement plan is will utilize a two-pronged approach in addressing the issue of administration of incorrect doses of medications in the medical and surgical wards. The first approach entails focusing on ensuring efficiency in the medication administration process to minimize the risk of medication errors through the adoption of a bar code medication administration system. Bar code medication administration system is a technology that is used in medication administration to minimize the risk of errors (Lin et al., 2018). The system enhances the efficiency of provision of care by automating most of the medication administration processes such as patient, medication, dosage, time, and route of administration identification and verification. The use of bar code medication administration system also streamlines other processes involved in the medication process such as prescribing, dispensing and ordering (Macias et al., 2018). Clinical nurses will have to be trained on the use of the system to increase their competencies and efficiency in the utilization of the bar code medication administration system. Nurses will also have to be mentored on the clinical use of the system to enhance the efficiency of its use and optimization of outcomes of care in nursing.  

The second quality improvement plan that is recommended for use to address the issue of the administration of incorrect dose of medication is focusing on the development of human resources in the organization (Kavanagh, 2017). It is recommended that the organization provide training and educational opportunities to nurses on issues related to safety, quality and efficiency in practice. The provision of training and educational opportunities on safety issues such as medication errors raises the level of awareness and skills of the nurses. The educational opportunities also enhance the adoption of new change initiatives in health organization to foster quality, safety and excellence (Yousef & Yousef, 2017). Therefore, scheduled training opportunities should be provided and evaluated to determine their effectiveness in promoting the realization of the organizational outcomes.  

Existing Organizational Resources 

The implementation of the above quality improvement plans requires the effective utilization of the organizational resources. One of the resources is financial support for the acquisition of the bar code technology to be used for medication administration. There is also the need for financial resources for use in providing training opportunities to the nurses on the safety and quality issues in their practice. The organization also has to utilize its existing resources such as nurse leaders and managers. Nurse leaders and managers are critical in providing the desired leadership and mentorship for the nurses in implementing the interventions utilized in the quality improvement plan. Therefore, the existing organizational resources should be utilized efficiently to minimize resource wastage in the implementation of the quality improvement plan.  

Conclusion 

Overall, the administration of incorrect dose of medications is one of the medication administration errors experienced in nursing practice. The administration of incorrect dose of medication has an adverse effect on the health and wellbeing of the patients. Nurses have a critical role in implementing quality improvement interventions to address this type of medication administration error. Therefore, the successful use of the existing organizational resources is anticipated to reduce and prevent incidences of medication administration errors in the organization.  

References 

Alemu, W., Belachew, T., & Yimam, I. (2017). Medication administration errors and contributing factors: A cross sectional study in two public hospitals in Southern Ethiopia. International Journal of Africa Nursing Sciences, 7, 68–74. https://doi.org/10.1016/j.ijans.2017.09.001 

Hammoudi, B. M., Ismaile, S., & Yahya, O. A. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences, 32(3), 1038–1046. https://doi.org/10.1111/scs.12546 

Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159–165. https://doi.org/10.12968/bjon.2017.26.3.159 

Latimer, S., Hewitt, J., Stanbrough, R., & McAndrew, R. (2017). Reducing medication errors: Teaching strategies that increase nursing students’ awareness of medication errors and their prevention. Nurse Education Today, 52, 7–9. https://doi.org/10.1016/j.nedt.2017.02.004 

Lin, J.-C., Lee, T.-T., & Mills, M. E. (2018). Evaluation of a barcode medication administration information system. CIN: Computers, Informatics, Nursing, 36(12), 596–602. https://doi.org/10.1097/CIN.0000000000000459 

Macias, M., Bernabeu-Andreu, F., Arribas, I., Navarro, F., & Baldominos, G. (2018). Impact of a barcode medication administration system on patient safety. Oncology Nursing Forum, 45(1), E1–E13. https://doi.org/10.1188/18.ONF.E1-E13 

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2020). Medication Dispensing Errors and Prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519065/ 

Thomas, L., Donohue-Porter, P., & Stein Fishbein, J. (2017). Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Journal of Nursing Care Quality, 32(4), 309–317. https://doi.org/10.1097/NCQ.0000000000000256 

Yousef, N., & Yousef, F. (2017). Using total quality management approach to improve patient safety by preventing medication error incidences**. BMC Health Services Research, 17(1), 621. https://doi.org/10.1186/s12913-017-2531-6 

In healthcare settings, patient falls pose a serious risk to patient safety since they can
result in serious injuries and higher medical expenses. This paper explains a sentinel event of a
patient fall in the hospital and how this event affects other medical teams in the hospital safety,
improvement plans made, and root-cause analysis (RCA) of this event. The RCA is a crucial
instrument in the healthcare industry for determining and resolving the causes of unfavorable
events. By addressing the fundamental causes of occurrences rather than merely their symptoms,
RCA is a methodical procedure that aims to prevent recurrence. Safety Improvement Plans
expand upon these discoveries by putting new procedures, focused activities, and professional
development programs into place to reduce hazards that have been identified. These strategies
play a critical role in maintaining patient safety, raising the standard of care, and encouraging a
continuous improvement culture.

Analysis of the Root Cause of Fall in Our Hospital

Mr. John Doe, a 68-year-old patient, fell on June 15, 2024, around 3 AM while
attempting to go to the restroom alone, despite being instructed to use the call button. Nurse
Kelly found him on the floor during her regular rounds and noticed the floor was wet, the
bathroom light was off, and the pressure bed cord was across the room. Mr. Doe explained that
he couldn’t reach his call light and believed the night nursing assistant had not properly set things
up after her shift. He sustained a small cut on his forehead and mild bruising on his left arm. The
fall caused him physical pain, emotional distress, and a decrease in confidence in the hospital’s
3
safety measures. The incident also caused stress and scrutiny for Nurse Kelly, the healthcare
staff, and the medical team involved in addressing the situation and participating in the Root
Cause Analysis (RCA) process. This event may have impacted their confidence and morale in
preventing such incidents.

You did a great job on this assessment! You thoroughly discussed and demonstrated how to use a root cause analysis to address areas of concern with patient safety, relating to preventing errors, such as patient ID errors. The safety improvement plan was logical and appropriate. Please see the comments below. Is this something that you think that you will consider doing at your place of practice? I always like to see when learners can take what they are learning in the classroom and apply it to practice making a difference in patient outcomes. Again, well done!

Faculty Comments:BRAVO! There were no APA formatting errors noted in the paper. This demonstrates your level of accountability and professionalism. Thank you for all your effort and time. Well done! If you would want to check it out, here’s a link to additional APA information: http://www.apastyle.org/learn/tutorials/basics-tutorial.aspx