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NURS FPX4020: Improving Quality of Care and Patient Safety
Root-Cause Analysis and Safety Improvement Plan
Medical error can be termed unfortunate but a reality that continues to occur in healthcare settings and at high rates in different nations. These medication-related mistakes or errors can result in unwanted and unimaginable consequences to the patient, family, clinicians, and healthcare organization (Rahmayanti et al., 2020). Today, care quality and patient safety have become critical indicators of an all-around effective healthcare system, practices, and professionals. Compromise on safety can result in unwanted feedback and patient experience. Efforts to improve the healthcare experience and address diverse issues affecting effective care delivery have fueled research to continue being conducted on the best way to address the identified problem and improve the overall functionality of the healthcare sector and system.
In the case of medication-related issues or errors, applying a root cause analysis can provide a beneficial remedy for clinicians and patients to further understand, combat, and improve on medical errors to address the problem at hand and prevent future occurrences. While sometimes it may be challenging to identify the root cause of an error, relevant players must evaluate strategies to mitigate such a problem in the future and the adverse effects that may be experienced. According to Mills (2016), the Joint Commission in the US demands hospitals and other care facilities occasionally undertake an analysis of sentinel events. The Root Cause Analysis (RCA) application provides a technique that helps care providers identify the causes of an issue. At the same time, it allows the development of a mitigation procedure for the identified problem. Using an RCA helps healthcare organizations regarding medication errors understand the error while helping mitigate the occurrence which compromises patient safety. This paper provides a detailed case analysis while adopting the Root-Cause analysis model to identify and establish a solution to the identified medication-related error based on a provided case scenario.
Case scenario for Root Cause Analysis Application
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide a definitive diagnosis, the team decided to treat the patient empirically with high-dose steroids. When discussing the patient on morning rounds, the senior resident instructed the intern quite clearly to “give the patient one gram of steroids.” After rounds (and some quick math), the intern ordered:
“Prednisone 20 mg tabs 50 pills PO x 1 now”
After receiving the written order, the pharmacist contacted the intern to clarify the order. She suggested to the intern that the one gram of steroids probably was supposed to be given in an intravenous form. The busy and harried intern stated firmly that he wished to give the patient fifty 20-mg pills. When the pharmacist persisted in questioning the order and gently suggested the intern may want to contact his senior resident for clarification, the intern refused and replied, “You can give it with a tablespoon of Maalox.” The patient was brought fifty 20-mg pills of prednisone and became angry and frustrated as he swallowed pill after pill. He developed mild nausea and heartburn while taking the prednisone. The following day, upon review of the medication record, the senior resident found the error. The oral prednisone was stopped, and the patient was correctly given a gram of intravenous methylprednisolone (Solu-Medrol). He eventually recovered from his vasculitis and was discharged in stable condition NURS FPX 4020 Assessment 2 Root Cause Analysis.
Analysis of the Root Cause
The primary incident entailed a wrong prescription administered to a patient (a middle-aged man), miscommunication between the care providers, non-adherence to implemented protocols, and lack of counter-checking as per the protocols. The incident also entailed poor implementation of safety measures. The error or medication issue identified in the case provided can be attributed to a host of intertwined factors, and one after the other resulted in the entire case unfolding. The attending senior resident noted the prescription and administration error after of prednisone error after the patient started experiencing nausea and heartburn after taking the pills.
To commence with, the on-duty physician questioned the patient prescription, which the nurse intern had presented, and even asked the intern to consult with the senior resident, but the intern insisted on the prescription he had ordered. The process resulted in the intern giving the wrong medication and dosage, which caused heartburn and nausea to the patient. Verbal communication for medications poses a threat and is a possible cause of misinformation and medication error. On another note, there lacked a defined hospital protocol regarding how prescriptions should be communicated. Despite being an emergency, it was justified not to overlook the protocol if it was present, hence a factor aggravating the error. Equally, there was negligence in hospitals’ safety measures in the prescription preparation room where the drug chart for how prescriptions should be done and who should do it. The physician should have contacted the senior resident instead of trusting the intern with such critical medical administration. Finally, although the facility may have a well-described protocol for handling emergency and high-risk medication, the on-duty intern had poor adherence to adopting and implementing safety measures and had also poor communication skills as he should have listened to the physician and contacted the senior resident before administration of the pills. Miscommunication and lack of counter-checkers also expanded the mistake. Nevertheless, after the issue was identified the following morning, there was a swift reaction to save the patient, where the senior resident ordered a gram of intravenous methylprednisolone (Solu-Medrol), and the patient later recovered and was discharged in stable condition. Finally, regarding the provided case, miscommunication, lack of cooperation between the physician and the intern, and non-adherence to safety protocols can be identified as the primary root causes of the medication administration error.
Application of the Evidence-Based Strategies
As identified, medication-related errors have been a significant concern in the healthcare industry, with their occurrence reducing safety and care quality (Mutair et al., 2021). Nevertheless, over the years, diverse research has been undertaken establishing different measures to help lower medication-related errors. Evidence-based practices not only mean addressing the identified error but also providing a lasting solution, improved safety, and patient experience. Based on the discussed case, diverse EBP practices could be adopted to address the factors resulting from the medication error. One critical measure is formulating and using communication protocols within the emergency unit and the entire healthcare delivery team. According to Tariq et al. (2018), communication deficit is a critical factor for errors in healthcare settings. However, adopting communication protocols would be vital in verbal communication. Standardized communication protocols within a healthcare team and facility help to define the flow of information, passing, and sharing of accurate information regarding patient information and medications.
Poor implementation and non-adherence to safety and related protocols within the healthcare setting can be significant barriers to effective care delivery and patient management (Mutair et al., 2021). When the recommendations are put into practice, policy actions must be taken to inform and educate the providers on how to incorporate them into a routine; resources must be made available to facilitate the adoption of the practice, and surveillance and monitoring protocols must be put in place to improve adherence (Tariq et al., 2018). Policies on how to handle non-adherence are also crucial. For instance, the current pharmaceutical error resulted from poor communication and non-adherence to safety protocols by both the physician and the intern. Adherence to the safety protocols can be facilitated by ensuring that staff members have easy access to critical updates and protocol revisions. On top of that, sloppy protocol monitoring led to errors. The attending nurse intern willfully disregarded the physician’s advice for him to contact the senior nurse NURS FPX 4020 Assessment 2 Root Cause Analysis.
Regarding a middle-aged man with suspected vasculitis, proper adherence to quality and safety protocols would be a critical foundation to minimize medication errors, and the incident could have been prevented. While the lack of adequate knowledge by the intern regarding medication could be a factor behind the mistake, healthcare organizations must adopt teamwork and regular training for nurses and other care providers to update them on new care practices (Mutair et al., 2021). Nurses are typically involved in drug delivery as direct caregivers and care coordinators in multidisciplinary care teams. They must be warned about dangerous drugs that need to be administered with special care. Development and adoption of safety ad protocols in a daily healthcare setting provide a foundation for an integrated and effective organizational culture driven by demand for excellence, hence improved safety, coordination, and quality care.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The increasing focus on patient experience, quality care, and safety has led to the constant adoption of quality improvement measures. According to Treiber & Jones (2018), quality improvement entails facilitating improvement in terms of the performance of healthcare operations and facilities and simultaneously improving the overall quality of health services. Regarding the discussed case, quality improvement would result in minimized medication errors by addressing the root causes. The practices to improve quality would target to address or improve the identified factors behind the medication error. Based on the specified case, quality improvement measures would focus on improved communication between physicians and nurses. There would be a need to adopt and implement a standard transmission, that is, written or electronically generated prescription, ensuring nurses have a reference for easy preparation and error identification.
Additionally, to improve the organization protocols for drug administration, there will be a need to develop new policies. Treiber & Jones (2018) identified that the presence and availability of information in healthcare settings increase care providers’ ability to accord effective care as planned, reducing errors caused by forgetting or mix-up. Additionally, the healthcare facility. Increased visualization creates an easy source of reference for nurses. While the actions will be focused on addressing any future medication error occurrence, the scenario provides a learning experience for the organization. The quality improvement practices would also serve as patient outcome improvement practices, achieve efficiency in care delivery, and reduce the cost of care due to medical errors.
Existing Organizational Resources
A multidisciplinary care team of doctors, nurses, and nurse informaticists is one of the organizational tools that will aid in improving the plan’s execution and results. In addition, the computers in the facility library will be crucial for supplying information to the caregivers on the current protocol. Financial resources will aid in the funding of research investigations that will help in the development of instructional programs on recently developed medicines NURS FPX 4020 Assessment 2 Root Cause Analysis. The currently available surveillance tools will ensure that the new protocols are followed.
In conclusion, medication-related errors are a major concern in healthcare sectors. With diverse adverse effects, organizations must develop effective evidence-based practices to avert the crisis resulting from medication-related errors. But identifying the issue’s root causes is the first step in solving it. This aids in creating a focused strategy to address the problem.
References
Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636“639.
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines , 8 (9), 46. https://doi.org/10.3390/medicines8090046
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.
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention. https://europepmc.org/article/NBK/nbk519065
Treiber, L. A., & Jones, J. H. (2018). After the medication error: Recent nursing graduates’ reflections on the adequacy of education. Journal of Nursing Education , 57 (5), 275-280. https://doi.org/10.3928/01484834-20180420-04
NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan 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. NURS FPX 4020 Assessment 2 Root Cause Analysis
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.
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.
NURS FPX 4020 Assessment 2 Root Cause Analysis
NURS FPX 4020 Assessment 2 Root Cause Analysis One Dose, Fifty Pills (AHRQ) Case Study from AHRQ WebM&M
https://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
Learning Objectives: At the end of this activity, you will be able to:
Identify the risks involved with improper supervision in a health care setting.
Discuss the importance of “speaking up” within a health care setting.
Explain how poor communication among health care providers can lead to negative experiences for patients.
Description: Told to give a patient one gram of steroids, an intern mistakenly orders fifty 20-mg pills. Although a pharmacist questions the order, the intern insists that the medication be given as ordered.
The Case
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide a definitive diagnosis, the team decided to treat the patient empirically with high-dose steroids.
When discussing the patient on morning rounds, the senior resident instructed the intern quite clearly to “give the patient one gram of steroids.” After rounds (and some quick math), the intern ordered:
“Prednisone 20 mg tabs 50 pills PO x 1 now”
After receiving the written order, the pharmacist contacted the intern to clarify the order. She suggested to the intern that the one gram of steroids probably was supposed to be given in an intravenous form. The busy and harried intern stated firmly that he wished to give the patient fifty 20-mg pills. When the pharmacist persisted in questioning the order and gently suggested the intern may want to contact his senior resident for clarification, the intern refused and replied, “You can give it with a tablespoon of Maalox.”
The patient was brought fifty 20-mg pills of prednisone and became angry and frustrated as he swallowed pill after pill. He developed mild nausea and heartburn while taking the prednisone.
The following day, upon review of the medication record, the senior resident found the error. The oral prednisone was stopped, and the patient was correctly given a gram of intravenous methylprednisolone (Solu-Medrol). He eventually recovered from his vasculitis and was discharged in a stable condition.
The Commentary
Lawrence Smith, MD, Chief Academic Officer, Senior Vice-President for Academic Affairs, North Shore-Long Island Jewish Health System
This case could easily be characterized as simply a humorous event associated with residency training. One can envision this story being retold with much laughter in the hospital cafeteria because of the seeming lack of common sense it demonstrates (and, of course, because the patient experienced minimal harm). However, it also may be a cautionary glimpse into the tenuous balance between residency training and patient safety.
Inherent in care in a teaching hospital is the fact that interns and residents, often the immediate caregivers to patients, are less experienced, less expert, less efficient, and perhaps more prone to medical errors. Despite this seeming risk, comparative studies actually report better quality of care for most conditions at teaching hospitals, albeit at higher cost.(1-3) The etiology of the advantage is unclear but may be secondary to better access to specialized services, better adherence to evidence-based medicine, or improved physician availability.
Notwithstanding these potential virtues, this case demonstrates that residents often have gaps in knowledge and experience that may place patients at risk. Such gaps can be overcome with both supervision and clinical maturation (after all, that is what residency is for). Since the latter accrues only over time, supervision is critical, particularly during early training. Against that background, this troubling case exposes how the unique culture of residency education, as well as the long-standing tradition of resident autonomy, are often at odds with patient safety.
Let’s look closer at the culture that allows an intern, clearly unsure of the specifics of a therapeutic intervention for an uncommon disease, to forge ahead despite his lack of knowledge and a warning from another trained professional that his decision might be in error. Highly relevant to this case is the “hidden curriculum” in medical education.(4) This term refers to the set of influences functioning at the level of organizational structure and culture, including, for example, implicit rules that permit trainees to survive the institution. These rules often take the form of customs and rituals, and they are usually taken for granted by virtually everyone. Within residencies, the hidden curriculum is one of intense loyalty to team, coupled with enormous respect for hierarchy and for specific roles within that team. Further, needing and requesting help from colleagues is often seen as failure. It is unclear whether the intern in this case feared humiliation if he requested help. However, it would not be surprising if such a fear was responsible, at least in part, for his failure to seek assistance even after it was recommended. Unfortunately, pride and shame can take precedence over patient safety.
Many residency programs also have a culture of devaluing input from non-physician professionals. Whereas experienced physicians might well have heeded the warning of the pharmacist or taken the advice of experienced nurses, young physicians in training, probably due to their own insecurity and their intense dependence on the resident team as the center of their professional life, may find it extremely difficult to take advice from non-physicians. In addition, housestaff in teaching hospitals are often paged or called by non-physician professionals, especially from the nursing staff, about non-urgent issues—those related to minor deviations from “hospital usual practice,” discharging a “legal obligation” to report minor patient issues to a physician, or focused on reducing “unnecessary” nurse/aide/phlebotomist workload during the day. It may be difficult for house officers to separate trivial queries from serious ones, and they may struggle with the “cry wolf” phenomenon. In our program, having a senior nurse and chief resident occasionally monitor “calls” has improved the quality of nurse-resident communication.
Let us now turn to the issue of autonomy. How can an intern believe that he shouldn’t call his senior resident or attending when a pharmacist, whose primary role in the hospital is to reduce medication errors, questions the medication order? Autonomy and physician (not just housestaff) independence have long histories in western medicine.(5,6) Physicians have consistently prized autonomy in clinical decision-making NURS FPX 4020 Assessment 2 Root Cause Analysis. There is no question that autonomy within those areas that require clinical experience and judgment (often referred to as “the art of medicine”) should be valued in our medical system. This would include the sorting of patient data, interpretation and weighting of the data, framing the clinical issues in the context of the individual patient, and making decisions in the face of uncertainty. However, if physicians are not following evidence-based medicine or, moreover, are harming patients as they exercise their independence, the autonomy should be curtailed in the name of safety and quality.
In resident education, supervision and monitoring of the quality of care can be accomplished by two primary mechanisms: system-based oversight and direct attending supervision. Specific system-based interventions that have been effective include computerized physician order entry (7), clinical decision-support systems (8), and having clinical pharmacists round with teams in the ICU.(9) Implementation of system-based oversight must be balanced with the need to promote education and a sense of autonomy for the housestaff. That is, computerized orders and decision support must be user-friendly and not simply viewed as a “hassle” by busy residents, nor be so prescriptive that residents never learn to think on their feet. Moreover, any system-based oversight must be educational; for example, when an intern is directed not to give warfarin with Dilantin, he or she should have easy access to a link that outlines the drug interaction.
Beyond system-based interventions, what is the right amount of attending supervision of residents? In considering this question, it is important to recognize that it is essential that physicians in training feel absolutely responsible for their patients. That element of emotional learning (10) is critical to physician development. If attending physicians are “micromanaging,” or if system-based changes severely limit resident decision making, new physicians may not learn to accept ultimate responsibility for patient care or function quickly and decisively in the midst of clinical uncertainty.
To meet these goals, the skilled supervisor provides what I call “close supervision from afar.” The attending should know everything that happens to the patient and collect enough of the primary data to be sure of its accuracy yet remain in the background unless absolutely necessary. That way, the learners feel complete personal responsibility for their patients. The degree of close supervision must be based on an assessment of the skills, knowledge, and clinical maturity of the specific learners and cannot be generalized to one-size-fits-all. It is critical that the attending not correct differences in style or legitimate alternative approaches to a patient but, rather, reserve corrective interventions to true clinical errors. Differences in approach should be discussed with trainees as colleagues, not mandated from the “top.”
Under the real-world pressures of increasingly stringent billing and compliance regulations and the moral imperative for patient safety, the days of “resident-run” services with minimal oversight are coming to a close. Teaching hospitals should actively strive to strike a balance between preserving the housestaff autonomy needed for educational development and the need for patient safety. How can this be accomplished? First, attempts should be made to change the hidden curriculum of resident education, striving to create an environment where young physicians are comfortable asking for help and willing to recognize and respond to the expertise of all members of the care team. Toward this end, some specific cultural training, such as that found in crew resource management programs, might be valuable. Second, system-based interventions can preserve patient safety and educate housestaff while hopefully preserving a sense of physician autonomy. In a different culture and system, the error in this case may have been avoided—the intern would have respected the pharmacist’s expertise or called for help when there was a question about the order. Or maybe the computer would have balked at the order for fifty 20-mg pills and redirected the intern NURS FPX 4020 Assessment 2 Root Cause Analysis.
The answer to this seeming conflict of autonomy versus patient safety is in creating a culture where everyone looks critically at clinical outcomes, focuses on best patient care, and actively addresses the priorities of clinical autonomy, clinical judgments, and evidence-based medicine. We need an environment in which young physicians are comfortable asking for help, are willing to recognize and respond to the expertise of all members of the care team, and see patient safety systems as supporting their goals of providing better patient care—not as hassles in an already over-loaded workday. Ultimately, the goal must be to create a culture that allows physicians to comfortably ask for help when they are beyond their area of competence while preserving the intense personal sense of commitment and responsibility for the quality of care of their patients.
Take-Home Points
Striking the appropriate balance between autonomy and supervision represents one of the greatest challenges of physician education.
Many training programs have a “hidden curriculum” that overvalues autonomy and loyalty to the team and underappreciates the input of non-physician professionals.
The effective supervising physician provides “close supervision from afar.”
As we improve both human and systems-based supervision (ie, through computerized order entry), it will be vital to retain trainees’ personal sense of responsibility for their patients NURS FPX 4020 Assessment 2 Root Cause Analysis
