Assignment: NSGCB 468 Reflection 3

Assignment: NSGCB 468 Reflection 3

Assignment: NSGCB 468 Reflection 3

This reflection is comprised of 2 sections, collectively totaling a minimum of 500 words. This activity is meant to help you build your knowledge in preparation for the competency assessment.

Complete your reflection by responding to all prompts.

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1) Multifactorial Medication Mishap RCA

Read on the Multifactorial Medication Mishap case study and the commentary that follows.

Complete the Root Cause Analysis worksheet to analyze the case.

Answer the following prompts:

Explain why a root cause analysis was appropriate for this situation.

Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care.

Cite a minimum of 2 peer-reviewed or evidence-based sources published within the last 5 years to support your responses in an APA-formatted reference page.

2) Quality Factors

Thoughtfully reflect to answer the following:

What factors do you see in practice that influence safe, quality patient-centered care?

Have those factors shifted or changed as your role as an RN has progressed or changed?

Do you think the factors will continue to change?

What factors do you see affecting safe, quality patient-centered care in 10 years?

Submit your reflection.

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Assignment: NSGCB 468 Reflection 3

Multifactorial Medication Mishap RCA

Analysis of problems that occur in the patient care setting is key to arriving at appropriate and effective solutions. One of the approaches used in such cases is the root cause analysis (RCA), which is a structured strategy used in the analysis of the adverse outcomes causes. Therefore, the RCA analysis was applied in the presented case since it can help offer insights that it was not appropriate to blame the nurse only for the medication error which occurred (Okes, 2019). The RCA was, therefore, used to provide a channel that helped the investigation team to explore all the possible causes of the medication error. Indeed, the use of RCA plays a key role in the identification of the system and human-connected causes.  Through this analysis, the team was able to ascertain that those who admitted the patient also played a role in the eventual mistake. Therefore, through the use of RCA, the team got enough information to resolve the situation and refrain from blaming specific individuals for the mistake.

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Various tools have continually been used to impact the safety and quality of patient care. Some of the tools include PDSA, FMEA, and RCA (Harkness& Pullen, 2019). The Plan-Do-Study-Act tool helps in guiding and testing change for quality improvement. As such, it is used in planning and implementing change initiatives focused on improving patient safety and quality and testing where the effects of the implemented change are negative or positive. FMEA is also important in the study of medical service processes and safety initiatives, with a major focus on avoiding failure and causes. Such is achieved by correcting the process. The use of RCA comes in cases where safety or quality-related errors occur (Harkness& Pullen, 2019). It is used to analyze such errors in terms of what led to the errors and how to avoid such errors. The end result is an improvement in quality and patient safety.

Quality Factors

Quality is a key aspect of patient care services. Hence hospitals and healthcare professionals use various strategies during practice to enhance quality and safety. Various factors are known to influence safe, quality patient-centered care. One such factor is organizational culture. An organizational culture that promotes evidence-based practice and research is likely to uphold practices that lead to safe, quality patient-centered care (Dang et al., 2021). For example, such a culture promotes interprofessional collaboration to achieve safety and quality goals. The other factor is communication. Effective communication between the healthcare professionals and between the leaders and other staff members can also positively include safe and quality patient-centered care. Other factors include laws, regulations and policies, and technology.

These factors have changed as my role as an RN has progressed. For example, one area that has significantly changed is communication. With the passing of time, I have become a better communicator, both to other staff members and patients. I have also improved my communication with the organization’s leaders. Interprofessional collaboration has also evolved as many nurse professionals and organizations keep on embracing collaboration as a way of improving patient outcomes. Therefore, leaders have continually encouraged professionals to collaborate and offer the necessary tools which can foster interprofessional collaboration. Another aspect that has been continuously changing is technology. New technology and technological applications have come almost every year to help improve patient outcomes (Tandon et al., 2020). I believe that some of these factors that impact safe and quality patient care will continue to change. For example, I think technology will continue to change and evolve, especially with the continuing prominence of artificial intelligence.

References

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau.

Harkness, T. L., & Pullen Jr, R. L. (2019). Quality improvement tools for nursing practice. Nursing made Incredibly Easy, 17(3), 47–51. https://doi.org/10.1097/01.NME.0000554602.68360.ed

Okes, D. (2019). Root cause analysis: The core of problem-solving and corrective action. Quality Press.

Tandon, A., Dhir, A., Islam, A. N., & Mäntymäki, M. (2020). Blockchain in healthcare: A systematic literature review, synthesizing framework and future research agenda. Computers in Industry, 122, 103290. https://doi.org/10.1016/j.compind.2020.103290