Patient Falls Fishbone Diagram Template for Root Cause Analysis

Fishbone Analysis Diagram

Part 1: Identify a problem in your practice environment. Use the Fishbone Analysis Diagram to conduct a root cause analysis.

Part 2: In 300-500 words, address the following:

What is the benefit of a root cause analysis in health care quality and safety? How does it mitigate risk?

Identify quality indicators for the selected problem and discuss their associated measurement strategies.

Describe the purpose of progress tracking in project management.

Describe how to identify project adjustments and when it is best to implement them.

The purpose of this Patient falls fishbone diagram template root cause analysis assignment is to use a Fishbone Diagram to complete a root cause analysis. Identify a problem in your practice environment and utilize the topic Resource “Fishbone Analysis Diagram Template” to work through the problem to the root cause. Refer to “Problem-Solving Your Fishbone Into a Wishbone,” located in the topic Resources to complete this assignment.

While APA style is not required for Part 1, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

Prepare Part 2 of the template according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

https://vanguardcommunications.net/fishbone-problem-solving/

Patient falls fishbone diagram template root cause analysis

Fishbone Analysis

Fishbone Analysis Diagram

Part 1: The identified problem is falls in hospitalized patients. Patient falls are a safety concern with physical, psychological, and economic consequences (LeLaurin & Shorr, 2019). Understanding the cause of falls can inform prevention and management interventions. Conducting a root cause analysis can establish all factors influencing the problem of falls in hospitals. Fishbone diagram is one tool applied in examining causes of practice issues in healthcare (Kumah et al., 2024; Martin-Delgado et al., 2020). The Fishbone diagram below illustrates the different contributing factors for falls in hospitalized patients, including patient, staff, hospital-based, and environmental factors

Part 2:

The Benefit of a Root Cause Analysis in Health Care Quality and Safety

Root cause analysis (RCA) involves identifying direct and indirect causes of a problem. The RCA provides decision-makers with information on the factors causing a particular issue. If done after an incident, it helps prevent recurrence of the problem. However, RCA is also conducted as part of project planning to identify potential risks and develop mitigation measures. In healthcare quality and safety, RCA enables leaders and teams to focus on the root of the problem. It clarifies the quality or safety issue (Martin-Delgado et al., 2020). For instance, patient falls are a safety concern and a practice issue. Identifying causes of fall incidence can enable unit or departmental leaders to develop and implement interventions to reduce patient falls. Decreased falls indicate improved healthcare quality and patient safety (LeLaurin & Shorr, 2019). Overall, RCA improves healthcare quality and safety through cause or risk identification.

Quality Indicators for Falls and Measurement Strategies

The quality indicators for patient falls are fall rates, injuries, and prevention practices. The fall rate is the number of fall incidents in 1000 patient days. Falls also cause injuries requiring further medical attention. Compliance with fall prevention protocols is another quality indicator because they affect the incidence of falls with or without injuries. Fall rates and prevention practices can be measured as part of quality improvement through systematic strategies. Healthcare professionals can use incident reports to record data pertinent to fall rate calculation, such as cases of falls, fall injuries, patient census, patient bed days, the unit where the fall occurred, and causes. To measure compliance or adherence, leaders can use process metrics, such as performance of fall risk assessment (LeLaurin & Shorr, 2019). The findings can determine the quality improvement interventions to consider.

T he Purpose of Progress Tracking in Project Management

Project tracking is an essential step in project management. It entails examining the project to ensure the change aligns with the initial goals. For instance, tracking a fall prevention project would entail establishing the fall and fall-injury rates, and staff compliance with the fall prevention practices. Usually, project tracking is done within a specific period as the project continues. The data can help establish if the project is meeting targets. Also, the project manager can take measures to keep it on track if the results indicate unmet goals (Browning, 2018). Continuous progress tracking supports the alignment of project activities with set goals and targets.

How To Identify Project Adjustments and When It Is Best to Implement Them

Project managers can use a few strategies to identify project adjustments. The first strategy is determining the causes and effects of unexpected changes or delays. The project manager should examine the impact that the changes or delays could have on the overall project. Next, the manager should communicate the changes and potential adjustments to the stakeholders. It is essential to collect the stakeholder feedback to inform adjustments. The other step involves prioritizing milestones (Browning, 2018). Having evaluated all these aspects, the project manager can proceed to revise the contingency plan and schedule Patient falls fishbone diagram template root cause analysis.

References

Ainani, N., & Irwan, A. M. (2024). Factors associated with the incidence of patient falls in hospitals: A scoping review. Journal of Integrative Nursing, 6 (2), 117-126. https://doi.org/10.4103/jin.jin_133_23 .

Browning, T. R. (2018). Planning, tracking, and reducing a complex project’s value at risk. Project Management Journal, 50 (1), 71-85. https://doi.org/10.1177/8756972818810967.

Kim, J., Lee, E., Jung, Y., Kwon, H., & Lee, S. (2022). Patient-level and organizational-level factors influencing in-hospital falls. Journal of Advanced Nursing (JAN), 78 (11), 3641-3651. https://doi.org/10.1111/jan.15254 .

Kumah, A., Nwogu, C. N., Issah, A. R., Obot, E., Kanamitie, D. T., Sifa, J. S., & Aidoo, L. A. (2024). Cause-and-effect (fishbone) diagram: A tool for generating and organizing quality improvement ideas. Global Journal of Quality and Safety in Healthcare, 7 (2), 85-87. https://doi.org/10.36401/JQSH-23-42 .

LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine, 35 (2), 273-283. https://doi.org/10.1016/j.cger.2019.01.007 .

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Miraa, J. J. (2020). How much of root cause analysis translates into improved patient safety: A systematic review. Medical Principles and Practice, 29 (6), 524-531. https://doi.org/10.1159/000508677 . Patient falls fishbone diagram template root cause analysis