NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan
University:
Capella University
NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan
Paper 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 in a health care setting of your choice as well as a safety improvement plan.
SCENARIO
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.
NOTE: I chose the Healthcare-Associated Infections (HAIs). The scenerio is attached.
Introduction
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.
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.
- Use the Root-Cause Analysis and Improvement Plan [DOCX] Download 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 specific patient safety issue in an organization.
- Apply evidence-based and best-practice strategies to address the safety issue.
- Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
- Identify 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.
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.
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Sample Answer
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
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