NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
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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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
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.
Create a feasible, evidence-based safety improvement plan.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify existing organizational resources that could be leveraged to improve a plan.
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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
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.
The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.
One of the case studies from the previous assessment.
A personal practice experience in which a sentinel event occurred.
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 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 Template [DOCX] 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 in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
Create a feasible, evidence-based safety improvement plan.
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:
Assessment 2 Example
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. A title page is not required but you must include a reference list as per the template.
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 FPX4020 Medical Errors in A Vila Health Root Cause Analysis
Root-Cause Analysis
Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.
Analysis of the Root Cause
Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:
What happened?
Who detected the problem/event?
Who did the problem/event affect?
How did it affect them?
Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or other source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:
What was supposed to occur?
Were there any steps that were not taken or did not happen as intended?
What environmental factors (controllable and uncontrollable) had an influence?
What equipment or resource factors had an influence?
What human errors or factors may have contributed?
Which communication factors may have contributed?
These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event.
Improvement Plan with Evidence-Based and Best-Practice Strategies
Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain:
Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
Support these recommendations with references from the literature or professional best practices.
A description of the goals or desired outcomes of these actions.
A rough timeline of development and implementation for the plan.
Existing Organizational Resources
Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.
A brief note on resources that may need to be obtained for the success of the plan.
Consider what existing resources may be leveraged enhance the improvement plan?
Root-Cause Analysis and Safety Improvement Planning Paper Sample
Patient safety is a matter of more than just reacting to incidents as they arise.
To foster a truly safe environment for patients in a facility, one must look for broader patterns in safety concerns and trace them back to their common root causes. And, after these root causes have been identified, careful planning must be undertaken to enact evidence-based strategies to mitigate these issues.
In this scenario, you will assume the role of the charge nurse of a care unit at Clarion Court Skilled Nursing Facility in Shakopee, MN, a part of the Vila Health network. Clarion Court has seen a steady rise in medication errors over the past six months, leading to a particularly serious medication error last week that nearly resulted in an overdose.
The administrator of the facility, Stephen Silva, has asked you to conduct a root cause analysis and Help with creating a safety improvement plan to address the increase of medication errors on the unit over the past several months. This is a very serious matter because patient safety is of the utmost concern and medication errors remain a top priority at health care settings. You are required to submit a root cause analysis and safety improvement plan based off the incidences reported surrounding medication errors.
RE: Safety at Clarion Court
From: Stephen Silva, Administrator, Clarion Court Skilled Nursing Facility
To: Benny
I know that you’re upset about last week’s medication error. We all are. I think we need to look at this as a wake-up call, one we probably should have gotten months ago. We’ve seen the rate of medication errors move up steadily for months now, along with bad moves on several other health and safety metrics.
We need to take this seriously! On top of immediate measures to prevent the specifics of last week’s error from recurring, I would like you to do some examination of the deeper issues at play. Please spend some time talking to the care staff in your unit, and perform a root cause analysis. What are our underlying issues that are causing medication errors and other safety errors? On top of that analysis, I’d like you to at least start putting some thought into what sort of evidence-based courses of action we can undertake to remediate this.
Many thanks! I look forward to hearing what you find out.
best,
Stephen
Marisa Pacheco
CNA
I’ve been here 6 months. In some ways, it feels like 6 years; in others, it feels like I’m still learning the ropes. One thing I have trouble with: the computer system we use for charts. I always think I get it, and then I get twisted around, and oh boy. It can get pretty confusing. A couple of times I’ve just gotten completely lost trying to enter basic information, and I get really upset and scared. And then it takes me forever to get out of the mess, and I fall behind. And if I have to ask for help, whoever it is that helps me falls behind, too.
It’s a really hard job. You get pretty fried by the end of a shift, especially if they change what shift you’re working on. I can get to be kind of a zombie after a couple of hours on my feet here. I had an incident – I still feel super bad about this – where I was helping a resident in the bath and she slipped because my attention drifted. She broke her hip, and had a really tough bunch of months after that. I felt terrible. And it all happened because I was zonked. I don’t handle meds, but I can’t imagine what it must be like for people trying to keep medications straight when their brains are mush at the end of a shift and they’ve been fighting with the computers the whole time.
Shonda McCrae
RN
I’ve been here three years. This was my first job after nursing school. I like it a lot! I love the connection with the residents – I feel like I’m doing my part to make their lives better a little bit each day.
In terms of safety, here’s the thing – in school and on the job here, I think I’ve had really good safety training. I know how to do things in ways that are safe for the residents and for me. I know the safety plan. But – but! Sometimes that training and those procedures don’t seem like they’re really meant for the real world. You always want to do things the right way, but then going completely by the book can be really fussy and take a long time. And you’ve got a million things to do and they’re all important and supposed to happen right now, and residents have needs and they’re urgent and, well, you get the picture. It’s a tough thing to balance, always following procedure and keeping up with your obligations.
Good example: I know one of the things that the state mentioned in their audit was a staff member not wearing gloves when touching a patient. Well, that was me. I’m not proud of that at all. But I was in the middle of doing a blood glucose check and my damn glove tore. I should have run and gotten another, but I didn’t have time, I was already behind. So I just yanked it off my hand and kept going, then I looked up and saw the inspector. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
Anyway. I guess that means a bigger nursing staff would make everything safer, right? Less stuff for each person to do, more time to do it 100% according to protocol?
Nora Church
RN
You want to talk about safety? Sure, I can talk about safety.
The biggest problem we have is that some of the people who work in support are lazy or just don’t know what they’re doing. I know I shouldn’t say this, but I have a hard time believing that the CNAs will follow the rules. CNAs or other people who help out. They don’t care about patient safety, they don’t follow the safety plan (what little there is of it), and they don’t want to take the time to learn the right way to do things, so they take shortcuts to get to their breaks or whatever. I believe that the other RNs will do their jobs right. I guess the LPNs, too, though a lot of them have had a lot of bad habits for a long time. But what about the nurses who don’t have licenses? Forget it.
People have the wrong idea that staff at skilled nursing facilities aren’t as good as hospital staff. Which drives me nuts! The name, “skilled nursing,” says it all. But then I think about our CNAs and, well, I get where people are coming from.
Rich Kim
CNA
You know what’s strange? It’s been three years since I moved here. That’s not very long at all. But other CNAs come and go so fast that I feel like I’m part of Clarion Court’s old guard. It really is a problem!
It means there are always a lot of people on the floor who are learning on the job. Even if they are very good at their jobs and have a lot of experience, they still need time to learn about Clarion Court. If you don’t know all of the residents, for example, the older man walking out the door with a firm look like he knows where he’s going might look like a visitor leaving when he’s actually a resident running away. I think that’s already happened here.
I also think we should do something about nursing staff who walk around with their noses in the air, thinking they’re too good to listen to CNAs when we have something to say. No matter how fancy your BSN nursing school was, we’re all still people with eyes and brains who can see things that are worth talking about.
Lisa Cotrone
LPN
How long have I been here? Wow! Before that, I spent a lot of time at the Good Shepherd Home in St. Louis Park. It’s funny, but I feel like I’m one of the last of my kind. At least where I work, it looks like all the new nurses are RNs, and a good number of them also have a BSN.
Anyway. Safety. We are called into meetings and told about the safety plan, and I don’t know what else. It’s good, but it’s just words written down. I’ve been here for quite a while. No matter what a piece of paper in a binder says, I know how to do things safely.
One thing that keeps happening to me is that there’s this wall that makes it hard to talk. We switch shifts, and sometimes it’s hard for me to keep up with Fatima from the morning shift. Don’t get me wrong, I think she’s very smart. She didn’t grow up speaking English, though, so her accent is pretty strong. And sometimes, I don’t understand what she says. Even when you ask her to explain, it doesn’t always help. This has kept me from knowing a couple of times about something going on with a resident that I should have known. We do have charts, which help, but they can only take you so far.
We get a lot of nurses and CNAs who were either born outside of the U.S. or who just moved here recently. I think that’s because of a few things. Partly because it’s a good first job, and partly because it’s expected in a lot of those cultures that you respect and take care of older people. And they think that working here or in places like this will help them do that. And it’s wonderful! But that means we have to deal with this language thing a lot. NURS FPX4020 Medical Errors in Vila Health: Root Cause Analysis
Vila Health: Root-Cause Analysis and Safety Improvement Planning
My Questions
Question:
After talking to the floor staff, what do you see as some root causes of Clarion Court’s safety problems?
Question:
What would you recommend as part of a safety improvement plan?
