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 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 

Sample Answer 2 for NURS-FPX4020 Root-Cause Analysis and Safety Improvement Plan

Irrespective of health conditions, all patients deserve high-quality care. Such care is achieved in safe care settings free from adverse events. Although health care organizations apply different strategies to optimize patient safety, adverse events that risk patients’ health still occur. A multicenter study by the World Health Organization (WHO) revealed that approximately 51% of patients admitted to Intensive Care Units (ICUs) develop healthcare-associated infections (HAIs), denoting a significant gap between the achieved and desired health outcomes (Haque et al., 2019). Broadly, root-cause analysis (RCA) evaluates the causes of such high-risk events to establish preventive measures. Therefore, the purpose of this RCA paper is to evaluate the causes of HAIs and develop a safety improvement plan.

Analysis of the Root Cause

HAIs are a significant health risk whose detection and prevention should be prioritized in health care settings. Haque et al. (2020) found that a lack of proper infection control and prevention strategies is a leading cause of HAIs in ICUs and other high-risk areas. Patients are affected differently depending on their health condition and the intensity of care needed. For instance, the risk for HAIs is high among patients using invasive devices, advanced in age, and with comorbidities (Cristina et al., 2021; Despotovic et al., 2020). Internally, nursing professionals detect HAIs as patients develop an issue not related to their condition within 48 hours. The impacts are profound since HAIs affect patients, nursing professionals, and care facilities. Among patients, HAIs increase the risk of other infections besides prolonging hospital rates and health management costs (Peters et al., 2022). As a major source of morbidity and mortality, HAIs ruin patient-provider relationships.

HAIs in ICUs and other areas due to inappropriate infection prevention and control programs denote infective response to human and technical components of environmental hygiene. According to Peters et al. (2022), the rates of HAIs are high in care facilities where environmental hygiene measures do not meet the desired standards. The technical component includes cleaning and disinfection of surfaces and devices, while the human component includes best practice implementation. Awareness of these issues is a foundation of effective control since care providers understand the source and magnitude of risk to formulate the desired response.

Application of Evidence-Based Strategies

HAIs are a multidimensional patient safety issue with varying causes. One of the factors leading to HAIs in ICUs and other areas is the lack of a hand hygiene policy. According to Mouajou et al. (2022), health care professionals’ hands are a leading source of HAIs transmission. As a result, transmission through hands could be prevented by complying with the established hand hygiene guidelines. Dependence on antibiotics is another cause of HAIs since excessive use leads to antibiotic resistance (Haque et al., 2020; Centers for Disease Control and Prevention, 2023). Like hands, surfaces increase the risk of HAIs transmission. Haque et al. (2020) found that infected and polluted hospital surfaces are a leading source of transmission of microbes that spread HAIs. These diverse factors underline the need for a multimodal intervention to achieve the desired outcomes.

HAIs prevention evidence-based strategies and best practices vary with the cause of infection, available resources, and the timeline needed for achieving the targeted results. An outcome-driven response should guide care providers when implementing a particular strategy. For instance, infection prevention and control policy and planning incorporate different interventions for reducing the risk of HAIs in care facilities (Haque et al., 2020). Such interventions include, hand hygiene policies, environmental hygiene, and patient education. Antimicrobial stewardship is also recommended to combat antibiotic resistance and promote the proper use of antibiotics in health care facilities (Centers for Disease Control and Prevention, 2023). Since the effectiveness of an intervention varies with the situation, care providers should implement the strategy with the potential to produce the most effective results.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Safety improvement should be focused on addressing issues hampering outcomes. Due to the multifaceted nature of HAIs, the most realistic intervention is infection prevention and control (ICP) policy and planning. Vital in ICUs and similar high-risk areas, the ICP policy and planning primary objective is ensuring HAIs risks are identified and addressed effectively (Haque et al., 2020). Its first component is a risk assessment to identify at-risk patients and cohort them into a contact precautions group. The second component is environmental hygiene to reduce the risk of transmission significantly. In this case, porous and non-porous surfaces that increase the risk of infection should be routinely cleaned and disinfected. The third component is sustainability through policy adoption and health education. The facility should ensure that the infection policy is adopted and that care providers and patients get adequate education to facilitate implementation as situations necessitate.

Programs for preventing HAIs enable health facilities to provide care that meets the desired outcomes. For instance, risk reduction through a clean, hygienic hospital environment is critical in reducing hospitalizations, morbidity, and high costs associated with HAIs (Peters et al., 2022). Similar outcomes would be achieved by implementing the plan in ICUs and other areas where HAIs are reported. The infection control and prevention program is also vital for improving compliance with government regulations. Through the Hospital Readmissions Reduction Program (HRRP), the Centers for Medicare & Medicaid Services (CMS) mandates care providers to coordinate care and adopt other interventions to reduce avoidable readmissions (CMS.gov, 2023). Infection control reduces readmissions by preventing HAIs. Importantly, the program is critical in improving patient-provider relationships that are usually ruined when care quality fails to meet patients’ expectations.

A clear implementation timeline is vital for effective goal-driven safety improvement plans. The proposed program can be designed in a month to ensure the resources, amount of work needed, and people responsible for each task are specified. Haque et al. (2020) advised care providers to collaborate with stakeholders when implementing intensive projects involving HAIs prevention. A similar approach is vital where the management, nursing professionals, program analysts, and departmental leaders collaborate to design and implement the program. Policy implementation can take approximately three months to ensure that all health professionals have the knowledge and resources needed for the routine cleaning and disinfection of hospital surfaces. Outcomes can be evaluated in six months to assess areas of improvement to make the plan sustainable.

Existing Organizational Resources

Resource availability and utilization affect the success of safety improvement programs. The current plan requires disinfectants, personnel, and education materials, among other resources. Adequate staff is essential to ensure regular cleaning and disinfection of surfaces, among other roles. As Kativu and Pottas (2019) noted, leveraging existing resources helps health organizations minimize management costs. The current nursing staff is a critical resource to enhance the improvement plan. Nursing professionals can be directly involved in risk assessment to place high-risk patients in respective cohorts, routine cleaning and disinfection of transmission areas, and patient education. To achieve the desired outcomes, the management should support nurses with essential financial and material resources.

Conclusion

Health care facilities should provide safe environments for patients irrespective of health conditions. HAIs are a severe health risk, increasing hospitalization, the risk of other infections, and health costs. A safety improvement plan is essential for care facilities to prevent HAIs and ensure patients receive high-quality care. As described in this paper, the root cause of HAIs is ineffective infection control in high-risk areas. As a result, an infection prevention and control program would effectively prevent HAIs in ICUs and other areas to ensure patient care meets the desired outcomes.

References

Centers for Disease Control and Prevention. (2023). Core elements of antibiotic stewardship. https://www.cdc.gov/antibiotic-use/core-elements/index.html#:~:text=Antibiotic%20stewardship%20is%20the%20effort,use%2C%20and%20combat%20antibiotic%20resistance.

CMS.gov. (2023). Hospital Readmissions Reduction Program. https://www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions#:~:text=What%20is%20the%20Hospital%20Readmissions,in%20turn%2C%20reduce%20avoidable%20readmissions.

Cristina, M. L., Spagnolo, A. M., Giribone, L., Demartini, A., & Sartini, M. (2021). Epidemiology and prevention of healthcare-associated infections in geriatric patients: a narrative review. International Journal of Environmental Research and Public Health, 18(10), 5333. https://doi.org/10.3390/ijerph18105333

Despotovic, A., Milosevic, B., Milosevic, I., Mitrovic, N., Cirkovic, A., Jovanovic, S., & Stevanovic, G. (2020). Hospital-acquired infections in the adult intensive care unit—Epidemiology, antimicrobial resistance patterns, and risk factors for acquisition and mortality. American Journal of Infection Control, 48(10), 1211-1215. https://doi.org/10.1016/j.ajic.2020.01.009

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., & Charan, J. (2020). Strategies to prevent healthcare-associated infections: a narrative overview. Risk Management and Healthcare Policy, 1765-1780. https://doi.org/10.2147/RMHP.S269315

Kativu, K., & Pottas, D. (2019). Leveraging intrinsic resources for the protection of health information assets. South African Computer Journal, 31(2), 150-161. http://dx.doi.org/10.18489/sacj.v31i2.536 

Mouajou, V., Adams, K., DeLisle, G., & Quach, C. (2022). Hand hygiene compliance in the prevention of hospital-acquired infections: a systematic review. The Journal of Hospital Infection, 119, 33–48. https://doi.org/10.1016/j.jhin.2021.09.016

Peters, A., Schmid, M. N., Parneix, P., Lebowitz, D., de Kraker, M., Sauser, J., … & Pittet, D. (2022). Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review. Antimicrobial Resistance & Infection Control, 11(1), 38. https://doi.org/10.1186/s13756-022-01075-1