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.
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.
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.
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Understanding What Happened |
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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? |
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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? |
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