Capella NURS-FPX4020 Assessment 1 Enhancing Quality and Safety

Capella NURS-FPX4020 Assessment 1 Enhancing Quality and Safety

Assessment 1 Instructions: Enhancing Quality and Safety

• For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses.

Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

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.

• Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.

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

• Explain factors leading to a specific patient-safety risk focusing on medication administration.

Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.

• Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
• Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.

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.

References for Capella NURS-FPX4020 Assessment 1

• Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.
• Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

Scenario

Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines.

Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.

For this assessment:

• Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.

Capella NURS-FPX4020 Assessment 1 Instructions

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks in a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in healthcare settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance the quality of care and promote medication administration safety in the context of your chosen healthcare setting.

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 that you know what is needed for a distinguished score.

• Explain factors leading to a specific patient-safety risk focusing on medication administration.
• Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
• Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
• Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
• Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

• Length of submission: 3–5 pages, plus title and reference pages.
• Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: References and citations are formatted according to current APA style.

Capella NURS-FPX4020 Assessment 1 Enhancing Quality and Safety: Medication Safety Sample Paper

Medication errors have significantly affected patient safety, as some have led to mortality or disability. Despite significant improvements by our health system to mitigate these errors, medication safety is still a concern due to various causes.

The Food and Drug Administration (FDA) defines a medication error as an event capable of causing inappropriate medication use or patient harm in the hand of the prescriber, administering clinician, patient, or consumer of the medication (Center for Drug Evaluation & Research, 2019).

In the FDA’s definition, medication errors are preventable. The purpose of this paper is to describe a situation where a medication error occurred, explain the specific risks for the patient, and describe the best nursing coordination strategies to improve patient safety.

Patient Scenario

Charlie is a 22-year-old white male who had an emergency appendectomy following acute appendicitis. His pain persisted even on day four after the resumption of oral intake, and his surgeon prescribed oral morphine medication 10 mg start dose that evening. RN, the oncoming nurse that evening, administered 10 milliliters of morphine solution for injection infusion because the patient had been on other intravenous infusions in the postoperative period.

The formulation given contained a 10mg/ml solution. Three hours about half an hour minutes after the administration of this solution, Charlie started vomiting the milk he had taken that evening and appeared to be in respiratory distress. Therefore, RN called Charlie’s surgeon to review him.

Factors Leading to Patient-Safety Risk

Various patient safety risks could have led to this patient’s risk for medication errors. These errors relate to healthcare professional practice, products, procedures, and systems. These errors can be traced back to product labeling, packaging, prescription, administration, and monitoring.

These patient-safety risks related to medication administration include but are not limited to inadequate or unclear instructions, illegible writing, lack of medication reconciliation, improper administration documentation (Rosenthal & Burchum, 2020), inappropriate drug selection during administration, and failure to continue or discontinue medications. More than one risk can contribute to a single occurrence of medication error due to medication administration.

A qualitative study by Schroers et al. (2020) classified these patient safety risk factors in medication administration into personal factors and contextual factors. Personal factors include fatigue and complacency, while contextual factors include interruptions (Rosenthal & Burchum, 2020), night shift duty, unavailability of administration guidelines (Wondmieneh et al., 2020), and heavy nurse workloads. According to Rosenthal & Burchum (2020), about 60% of these medication errors occur during the care transition. Personal and contextual factors come into play at this time.

Improving Patient Safety Focusing on Medication Administration and Reducing Costs

Every healthcare organization continually works on various measures that they can use to prevent medication errors. Some of the evidence-based strategies to reduce medication errors, especially relating to medication administration, include but are not limited to the adoption of technology, bedside shift reporting, patient education, improving documentation in writing, and medication reconciliation. Adverse events from medication errors are too costly to the healthcare system and the patient. Treating adverse events due to medication increases the medical costs due to unintended patient harm and can cost the patient their lives.

The adoption of technology improves medication prescription and decision-making. According to Rosenthal & Burchum (2020), using technology reduces medication errors by 50%. The use of technology systems such as computerized physician order entry and computerized clinical decision support systems ensures that reduces errors of reception while the use of barcoded technology that identifies the drugs’ barcodes and against the patient information reduces errors of administration by up to 85% in some institutions (Rosenthal & Burchum, 2020). Therefore, technology can play a crucial role in the prevention of medication errors in the whole continuum of patient treatment.

Medication reconciliation is the process of comparing and updating the patient’s old and new medication lists. Medication reconciliation can be carried out at all care transitions, including inter-institutional transfer, admission, and discharge during shift reporting. About 60% of errors are reduced when medication reconciliation at all points of care transition. Bedside shift reporting offers an excellent opportunity for medication reconciliation during care transitions.

The Institute for Safe Medical Practices (ISMP) recommends using brand and generic names of medication during a prescription to ensure that during administration, the nurse is sure and less likely to make medication errors. The joint commission (TJC) banned the use of some abbreviations in prescriptions to reduce the chances of confusion during medication administration.

Improving documentation includes reserving verbal prescriptions for emergencies only. Documentation using electronic means ensures good communication between nurses, dispenses of medication, and prescribers of the medications. On the other hand, patient medication requires developing strong collaborative relationships that improve compliance with prescriptions to reduce the chances of medication errors (MacDowell et al., 2021). Education improves their understanding of the need for compliance and the potential side effects of overdose and toxicity.

Nursing Care Coordination to Increase Patient Safety

Nursing care is the center for care coordination in any healthcare institution. During care coordination, nurses organize patient care activities and share pertinent information with care stakeholders to ensure care effectiveness, safety, and quality (Agency for Healthcare Research and Quality, 2018). Care coordination aims at meeting patient care needs thus, the nurse needs to identify all patient needs and ensure they are met by the care providers. Some of the care coordination strategies that the nurse would employ include interprofessional collaboration and medication management.

For example, during interprofessional collaboration, the nurse can help with care transition, assess patient needs, and share all relevant information. The shared relevant information would be used to develop patient medication lists with a low risk of drug interaction and adverse events such as allergies. During care coordination, the nurse should also conduct medication reconciliation at every point of change in patient care providers. These two strategies would increase patient safety relating to medication administration.

Stakeholders During Care Coordination

The nursing care coordination must account for all relevant stakeholders of patient care. These stakeholders can be patient-specific and may not apply to all patient cases. Some of the key stakeholders that the nurse has to coordinate with include but are not limited to patient physicians, informaticists, pharmacists, patient caregivers, and the patient themselves. This coordination requires constant, timely communication and collaboration (Agency for Healthcare Research and Quality, 2018).

Collaboration with the patient or their caregivers would be important in safety monitoring and improving compliance with the prescription. Whenever in doubt, the nurse must coordinate with the prescribers of the patient medication lists to ensure that the correct drug and dosage are given to the patient, thereby lowering safety risks, especially due to administration. The nurse must coordinate with the pharmacists to ensure that the correct medication is dispensed. Their collaboration will also ensure that the risk of drug-drug interactions is lowered through medication reconciliation.

Another critical coordination is with fellow nurses. Collaboration with other nurses is essential in various ways. Firstly, it improves job satisfaction, thus lowering the chances of medication and medical errors. This interprofessional coordination and collaboration also enhance fast and smooth medication reconciliation (Tariq et al., 2022). This usually happens during shift handover. The exchange of other essential patient information at this time is also made easy through mutual information sharing and setting new care plans and care goals.

Conclusion

The medication error in this paper involved an overdose that could be due to a myriad of factors ranging from prescription to administration. Documented literature evidence has reported that medication errors due to medication administration arise from personal and contextual factors. Contextual factors are systemic and relate to the circumstances of the error occurrence. Personal factors related to complacency and fatigue from nurses.

To improve patient safety by preventing medication errors, the nurse should adopt strategies such as medication reconciliation, the use of technology, improving documentation, and patient education. Nursing care coordination strategies such as identifying patient needs and sharing information should involve all pertinent patient care stakeholders.

The patient caregivers, doctors, pharmacists, informaticists, the patient themselves, and other nurses and key stakeholders that the nurse will require to communicate and collaborate with to improve patient safety. Medication reconciliation at every point of care transition will be important during the coordination process.

References

• Agency for Healthcare Research and Quality. (2018, August). Care Coordination. Ahrq.gov. Retrieved from https://www.ahrq.gov/ncepcr/care/coordination.html
• Center for Drug Evaluation & Research. (2019, August 23). Working to Reduce Medication Errors. U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors
• MacDowell, P., Cabri, A., & Davis, M. (2021). Medication Administration Errors. Intensive Care Medicine. https://psnet.ahrq.gov/primer/medication-administration-errors
• Rosenthal, L., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
• Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. Joint Commission Journal on Quality and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010
• Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and prevention. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/
• Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1), 4. https://doi.org/10.1186/s12912-020-0397-0

Capella NURS-FPX4020 Assessment 1 Enhancing Quality and Safety Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Explain factors leading to a specific patient-safety risk focusing on medication administration.	Does not identify factors leading to a specific patient-safety risk focusing on medication administration.	Identifies factors leading to a specific patient-safety risk focusing on medication administration.	Explains factors leading to a specific patient-safety risk focusing on medication administration.	Explains factors leading to a specific patient-safety risk focusing on medication administration. Makes reference to specific data, evidence, or standards to illustrate the safety risk.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.	Does not identify evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.	Identifies evidence-based and best-practice solutions to improve patient safety focusing on medication administration and/or discusses reducing costs but not both.	Explains evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.	Explains evidence-based and best practice solutions to improve patient safety focusing on medication administration and reducing costs. Makes explicit reference to scholarly or professional resources to support explanation.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.	Does not identify how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.	Identifies how nurses can help coordinate care to increase patient safety with medication administration and/or how to reduce costs but not both.	Explains how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.	Explains how nurses can help coordinate care to increase patient safety with medication administration and reduce costs, providing specific examples related to a patient safety risk.
Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.	Does not identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.	Identifies stakeholders, but their relevance to collaboration with nurses or their ability to drive quality and safety enhancements with medication administration is unclear.	Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.	Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration, noting the relevance and potential importance of the stakeholders.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Does not organize content for ideas. Lacks logical flow and smooth transitions.	Organizes content with some logical flow and smooth transitions. Contains errors in grammar or punctuation, word choice, and spelling.	Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.	Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.	Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

Resources: Collaboration and Leadership

Cho, S. M., & Choi, J. (2018). Patient safety culture associated with patient safety competencies among registered nurses. Journal of Nursing Scholarship, 50(5), 549–557. https://doi-org.library.capella.edu/10.1111/jnu.12413

• This article discusses the importance of creating a unit-specific patient safety culture that is tailored to the competencies of the unit’s RNs in patient safety practice.

SonÄŸur, C., Özer, O., Gün, C., & Top, M. (2018). Patient safety culture, evidence-based practice and performance in nursing. Systemic Practice and Action Research, 31(4), 359–374.

• Evidence-based practice is a problem-solving approach in which the best available and useful evidence is used by integrating research evidence, clinical expertise, and patient values and preferences to improve health outcomes, service quality, patient safety and clinical effectiveness, and employee performance.

Stalter, A. M., & Mota, A. (2017). Recommendations for promoting quality and safety in health care systems. The Journal of Continuing Education in Nursing, 48(7), 295–297.

• This article provides recommendation to promote quality and safety education with a focus on systems thinking awareness among direct care nurses. A key point is error prevention, which requires a shared effort among all nurses.

Manno, M. S. (2016). The role transition characteristics of new registered nurses: A study of work environment influences and individual traits. (Publication No. 10037467) [Doctoral dissertation, Capella University].

• This research study may be helpful in identifying traits and qualities of new registered nurses that are helpful in coordinating and leading quality and safety measures related to this assessment.

Boomah, S. A. (2018). Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. Journal of Advanced Nursing. 75(5), 1000–1009. https://doi-org.library.capella.edu/10.1111/jan.13895

• This research analyzes attributes and best practices of leadership and nursing staff that help aid in patient care quality and job satisfaction.

Greenstein, T. (2020). Leading innovation is completely different from leading change. WWD.com.

• This article examines competencies that may help nurses collaborate more effectively to improve patient outcomes.

Poder, T. G., & Mattais, S. (2018). Systemic analysis of medication administration omission errors in a tertiary-care hospital in Quebec. Health Information Management Journal, 49(2-3), 99–107.

• This examination of underlying systemic causes of medication errors may be useful as you consider QI vest practices and ways to coordinate care to increase safety and quality.

Antevy, P. (2017). How care collaboration is improving patient outcomes. EMS World, 46(4), 26–33.

• This article examines competencies that may help health care professionals collaborate more effectively to improve patient outcomes.

Keers, R. N., Plácido, M., Bennet, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018, October 26). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLOS One. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206233

• This examination of underlying systemic causes of medication errors may be useful as you consider QI best practices and ways to coordinate care to increase safety and quality.

Quality and Safety Education

Lyle-Edrosolo, G., & Waxman, K. (2016). Aligning healthcare safety and quality competencies: Quality and safety education for nurses (QSEN), the Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® standards crosswalk. Nurse Leader, 14(1), 70–75.

• This article attempts to align the language used in three quality and safety standards and reduce confusion for health care professionals.

Altmiller, G., & Hopkins-Pepe, L. (2019). Why quality and safety education for nurses (QSEN) matters in practice. The Journal of Continuing Education in Nursing, 50(5), 199–200.

• This article discusses the needs for quality and safety education in nursing and how the Journal of Continuing Education in Nursing supports QSEN competency implementation in practice.

Johnson, L., McNally, S., Meller, N., & Dempsey, J. (2019). The experience of undergraduate nursing students in patient safety education: A qualitative study. Australian Nursing and Midwifery Journal, 26(8), 55.

• This article discusses educating nursing students about patient safety early within their learning journey and how it has shown to have a compelling positive impact on each individual’s knowledge, skills, and behavior growth surrounding the concept of patient safety.

Wieke Noviyanti, L., Handiyani, H., & Gayatri, D. (2018). Improving the implementation of patient safety by nursing students using nursing instructors trained in the use of quality circles. BMC Nursing, 17(2).

• Abstract: It is recognized worldwide that the skills of nursing students concerning patient safety is still not optimal. The role of clinical instructors is to instill in students the importance of patient safety. Therefore, it is important to have competent clinical instructors. Their experience can be enhanced through the application of quality circles. This study identifies the effect of quality circles on improving the safety of patients of nursing students. Patient safety is inseparable from the quality of nursing education.
• Existing research shows that patient safety should be emphasized at all levels of the healthcare education system. In hospitals, the ratio between nursing students and clinical instructors is disproportionately low. In Indonesia, incident data relating to patient safety involving students is not well documented, and the incidents often occur in the absence of a clinical instructor (Wieke Noviyanti, Handiyani, & Gayatri, 2018).

Havaei, F., MacPhee, M., & Dahinten, V. S. (2019). The effect of nursing care delivery models on quality and safety outcomes of care: A cross‐sectional survey study of medical‐surgical nurses. Journal of Advanced Nursing, 75(10), 2144–2155.

• This study examines components of nursing care delivery and the mode of nursing care delivery. This may be helpful in seeing safety and quality education and best practices.

Health and medicine – quality of care; new findings from Karolinska Institute in the area of quality of care reported (shared responsibility: school nurses’ experience of collaborating in school-based interprofessional teams). (2017, July 21). Health and Medicine Week.

• This wire feed examines evidence-based and best-practice strategies for improving the care offered by school nurses, may help you identify useful strategies for your assessment.

Quality and Safety Case Studies

Consider reviewing the following case studies as you complete your assessment:

• Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
• Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx

NURS-FPX4020 Assessment 2

• https://courserooma.capella.edu/webapps/osv-kaltura-BBLEARN/LtiMashupPlayIframeWrapperResponsive?playUrl=/browseandembed/index/media/entryid/1_bb79ixrv/showDescription/false/showTitle/false/showTags/false/showDuration/false/showOwner/false/showUploadDate/false/playerSize/608×402/playerSkin/43969931/&course_id=_344730_1&content_id=@X@content.pk_string@X@
• !!!!!If you click this link, it will explain all the instructions!!!!!
• For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

As patient safety concerns continue to be addressed in the health care 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 health care 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.

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.
  • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
  • Create a viable, evidence-based safety improvement plan for safe medication administration.
• Competency 2: Analyze factors that lead to patient safety risks.
  • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
• Competency 3: Identify organizational interventions to promote patient safety.
  • Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
• Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

Nursing practice is governed by health care 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.

Scenario

For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

• The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
• The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

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 health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Please utilize the template

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

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 pertaining to medication administration in an organization.
• Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
• Create a feasible, evidence-based safety improvement plan for safe medication administration.
• Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

• Assessment 2 Example [PDF].

Additional Requirements

• Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
• 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.
• APA formatting: Format references and citations according to current APA style.

• SCORING GUIDE

Root-Cause Analysis and Safety Improvement Plan Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Does not identify the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.	Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Does not describe evidence-based and best-practice strategies pertaining to medication administration.	Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.	Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration, detailing how the strategies will address the safety issue or sentinel event pertaining to medication administration.
Create a viable, evidence-based safety improvement plan for safe medication administration.	Does not create a viable, evidence-based safety improvement plan for safe medication administration.	Creates a safety improvement plan for safe medication administration that lacks appropriate, convincing evidence of its viability.	Creates a viable, evidence-based safety improvement plan for safe medication administration.	Creates a viable, evidence-based safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for safe medication administration are unclear.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.	Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration, prioritizing them according to potential impact.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Does not organize content for ideas. Lacks logical flow and smooth transitions.	Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling.	Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.	Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.	Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.	Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

Evidence-Based Practice

• Hande, K., Williams, C. T., Robbins, H. M., & Christenbery, T. (2017). Leveling evidence-based practice across the nursing curriculum. The Journal for Nurse Practitioners, 13(1), e17–e22.
  • Abstract: Evidence-based practice (EBP) competencies represent essential components of nursing education at all levels. The transition of EBP learning goals from the baccalaureate to the Master of Science in nursing and Doctor of Nursing Practice levels provides a blueprint for the development and advancement of student knowledge, skills, and attitudes. The purpose of this article is to describe 3 nursing curricula related to EBP competencies at the baccalaureate, master’s, and Doctor of Nursing Practice levels (Hande, Williams, Robbins, & Christenbery, 2017).
• Sukkarieh-Haraty, O., & Hoffart, N. (2017). Integrating evidence-based practice into a Lebanese nursing baccalaureate program: Challenges and successes. International Journal of Nursing Education Scholarship, 14(1), 441–442.
  • Abstract: Evidence-based practice (EBP) is defined as “the conscientious use of current best evidence in making clinical decisions about patient care.” This paper describes how we have developed the evidence-based practice concept and integrated it into two courses at two different levels of the BSN curriculum. Students apply EBP knowledge and process by using the PICO clinical question (Population, Intervention, Comparison and Outcome), whereby they observe a selected clinical skill, and then compare their observations to hospital protocol and against the latest evidence-based practice guidelines. The assignment for the second course requires students to pick a more complex clinical skill and to support proposed changes in practice with scholarly literature. Assessment of student learning and course evaluation has shown that the overall experience of integrating EBP projects into the curriculum is fruitful for students, clinical agencies, and faculty (Sukkarieh-Haraty & Hoffart, 2017).
• Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, barriers and potential strength of nursing in implementing evidence-based practice. International Journal of Caring Sciences, 13(2), 1203–1211.
  • This article provides methods for identifying the readiness, barriers, and potential strengths of implementing evidence-based practice.
• Lee, S. K. (2016). Implementing evidence-based practices improves neonatal outcomes. Evidence-Based Medicine, 21(6), 231.
• • This journal article provides a framework for identifying and appraising research, as well as implementing change and practices based on research.

Quality and Safety

• Ambutas, S., Lamb, K. V., & Quigley, P. (2017). Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units. Medsurg Nursing, 26(3), 175–179, 197.
  • The implementation of a safety improvement project is examined in this article.
• Institute for Healthcare Improvement. (n.d.). Why is reducing harm – not just error – important to patient safety? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/Bates-Reducing-Harm-Important-To-Patient-Safety.aspx
  • Based on the premise that human error may be reduced but not avoided in every health care situation, this video focuses on the importance of harm reduction to patient safety.
• The Joint Commission. (2018). 2018 national patient safety goals. https://www.jointcommission.org/standards_information/npsgs.aspx
  • The patient safety resources on this Web page may be helpful as you develop the improvement plan section of your assessment.
• Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636–639.
  • This article summarizes the creation of a safety program to reduce sentinel events.
• U.S. Department of Health & Human Services. (n.d.). https://www.hhs.gov/
  • Explore numerous resources related to quality and safety on this website as you develop your assessment submission.

Root-Cause Analysis

• Institute for Healthcare Improvement. (n.d.). Cause and effect diagram [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard16.aspx
  • Cause and effect (or fishbone) diagrams are often used in root-cause analyses; this video shows how to create them.
• Institute for Healthcare Improvement. (n.d.). Introduction to trigger tools for identifying adverse events. http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
  • Tools to identify adverse events and determine their causes are provided on this resource page.
• Galatzan, B. J. (2019). Exploring the content of the nurse-to-nurse change of shift hand-off communication (Publication No. 27666610) [Doctoral dissertation, University of Arizona]. http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2336369734%3Faccountid%3D27965
  • Abstract: An estimated 250,000 deaths occur annually are attributed to preventable medical errors. Approximately 100,000 of those deaths are related to miscommunication between healthcare providers. Miscommunication between healthcare providers during the transfer of care accounts for 80% of sentinel events occurring in the hospital setting. The hand-off communication continues to be one of the primary causes of sentinel events in healthcare in spite of the continued research focus over the past 10 years. The transfer of care communication between providers is called the “hand-off,” “change of shift report,” or “handover.” The hand-off for purposes of this study is defined as the process of transferring patient care, responsibility, and authority from one nurse to another at the change of shift. Specifically, we are concerned about the communication of clinical events (CE) experienced by the patient because CEs are precursors to a sentinel event. A CE is defined as a change in the patient’s condition in the following areas: bleeding, pain, fever, and changes in output, respiratory status, or level of consciousness (Galatzan, 2019).
• Minnesota Department of Health. (n.d.). Root cause analysis toolkit. https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/
  • The Minnesota Department of Health offers an extensive collection of resources related to root-cause analysis.
• The Joint Commission. (n.d.). Framework for conducting a root cause analysis and action plan. http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/
  • With resources for conducting a root-cause analysis and creating an action plan to address the results, this Web page will help you understand the steps and processes of RCAs and improvement plans for this assessment.

Sentinel Events

• The Joint Commission. (n.d.). Sentinel event policy and procedures. https://jointcommission.org/sentinel_event_policy_and_procedures
  • This web page provides definitions, policies, and procedures related to Sentinel events that may help you to complete your assignment.
• The Joint Commission. (2017). The essential role of leadership in developing a safety culture [PDF]. Sentinel Event Alert, 57, 1–8. https://www.jointcommission.org/sea_issue_57/
  • According to The Joint Commission, “Competent and thoughtful leaders…understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.” This issue of Sentinel Event Alert discusses ways that effective leaders foster the development of a safety culture.

Safety and Sentinel Event Case Studies

• Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
• Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx