-
QUESTION
Safety Improvements
For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue.
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: MUST FOLLOW TEMPLATE PROVIDED attached
•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.
•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, 3 scholarly sources, 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.
Root-Cause Analysis and Safety Improvement Plan
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.
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 another 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.
Application of Evidence-Based Strategies
Identity best practices strategies to address the safety issue or sentinel event.
- Describe what the literature states about the factors that lead to the safety issue.
- For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.
- Explain how the strategies could be addressed in safety issues or sentinel events.
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 to enhance the improvement plan
Conclusion
References
| Subject | Nursing | Pages | 10 | Style | APA |
|---|
Answer
Root-Cause Analysis and Safety Improvement Plan for Patient Fall
Root-Cause Analysis
Research carried out in healthcare facilities across the US depict at least a million falls are reported each year. Most of the people who succumb to falls in hospitals are elderly or frail patients (Morris & O’Riordan, 2017). A patent fall is when a patient plummets to the floor of a healthcare facility unexpectedly incurring injuries or subsequently falling with none. A patient fall may lead to minor injuries such as bruises and cuts on the skin, or more injuries that are serious, including internal bleeding or bone fractures (PS Net, 2019). Safety improvement plans to help address issues concerning patient safety like patient falls. Therefore, a safety improvement plan involving a case scenario on patient falls, an application of evidence-based practice (EBP) strategies and implementation of organizational resources will help in reducing patient fall as an issue in healthcare.
Case Scenario
While attending my practicum, I recently witnessed a patient fall scenario that warranted the need for a safety improvement plan against the issue. Walking into my morning shift, I found YZ laying on the floor close to the wardroom door.
YZ is a 75-year-old retired marine biologist currently admitted to the elderly ward after suffering a home accident displacing his hip joint that necessitated physiotherapy treatment. The wife mentioned his struggle scaling the home staircase where he has repeatedly fallen with no injuries until this recent fall. His medical shows that he uses a pacemaker. While at the hospital, YZ became increasingly agitated and suffered from insomnia. He takes at least six different medications for his heart, diabetes, and blood pressure. His vision had become blurry, and YZ had refused to take a vision test over the last two years.
The patient fall affected the patient who suffered bodily harm when he fell to the floor. YZ suffered increased injuries to his already displaced hip joint as he was reeling in pain on the floor.
Analysis of the Root Cause
Further investigation into the patient’s case showed that patient-related factors, medication, and nursing error led to the patient’s fall. YZ takes medication that makes him weak and increases his chances of having a fall (Najafpour et al., 2019). Moreover, having had prior incidences of falls at home put YZ at an increased chance that he might be prone to have fallen. The nursing error that occurred was that the overnight nurse forgot to place the guard railing up after checking on YZ, therefore, due to his insomnia, he got up and in his weak debilitating state fell at the room’s door.
Additionally, human factors and environmental factors necessitated YZ’s fall. As an environmental factor, stress and worry may cause forgetfulness and distractions while nurses attend to patients (Chaneliere et al., 2018). The overnight nurse, on receiving news that his son was rushed to the ICU was stressed to the point of forgetting to put up the patient’s hospital bed guardrail after checking on him that night. Human factors like the patient’s stress on drugs and insomnia also contributed to the patient’s fall. YZ’s insomnia kicked in, and in his weakened debilitating state, got out of bed and fell beside it. All through, no technical factors contributed to YZ's fall.
YZ’s scenario shows the need for implementing evidence-based strategies as medication made him weak, leading to his fall. Induced by his apparent insomnia, YZ’s must have woken up in the middle of the night agitated and felt the urge to leave his room having that the guardrail was placed down. His blurred vision from medication he was taking and weakened state led to his inevitable fall after his body would carry him as far as his wardroom’s door. Therefore, YZ’s fall necessitates the inclusion of evidence-based practice (EBP) strategies towards addressing patient falls. EBP strategies will help in making sure that proper patient care is administered to patients while reducing the causes of patient falls in healthcare facilities.
Application of Evidence-Based Practice Strategies
- Patient Safety Rounds (Hourly rounds)
Description
The organization should direct the nurses to conduct hourly rounds on high-risk fall patients.
Desired Outcomes
The hourly rounds will help push the goal to ensure all safety protocols work for patients who may be at a high risk of falling (Becker’s Staff, 2020). Also, nurses will prevent patients from contacting other injuries or infections.
- Color-coded Socks or Wristbands
Description
The organization should employ the use of color-coded socks and wristbands that differentiate high-risk falling patients from other patients.
Desired Outcomes
Caregivers will quickly know such patients through such identification processes (Becker’s Staff, 2020).
- Bed Alarm Installation
Description
The organization should look into installing bed alarms to alert the nurses’ station when high-risk fall patients have been away from the bed longer than a designated period. The bell alarms should be set with an interval that indicates the nursing station that a high-risk fall patient has left the bed (Morris & O’Riordan, 2017). If the patient does not return to the bed in a designated time, for example, 20 seconds, the nurses' station should be notified as the bell goes off.
Desired Outcomes
The alarms will help in faster responses from nurses to check on the condition of the patient. This will help reduce the number of incidences of patient falls in the hospital.
- Safety Company
Description
The organization should train safety companions for high-risk fall patients.
Desired Outcomes
Safety companions will help reduce the cases of patient falls by being readily available in case a patient will need to move around. The companions will as well help reduce the nurses workload by attending to the patient before the nurse comes, therefore reducing cases of patient falls.
Implementation Timeline
Table 1: Implementation timeline for the suggested improvement to reduce patient falls. Source: Own creation.
|
Item |
Period |
|
Safety Companion Training |
6 months |
|
Acquisition of color-coded socks or wristbands |
2 weeks |
|
Installation of bed alarms |
1 month |
|
Implementing hourly nurse rounds |
6 months |
Existing Organizational Resources
The healthcare facility has in place already, raising awareness, a standardized identification tool, and individualized care plans as resources to reduce patient falls. The facility educates all personnel on steps in preventing patient falls. For example, the cleaning staff have labelled signs in case of a wet or slippery floor. Individualized care plans have also been made, including injury risks and action plans towards each patient's physical condition. Lastly, the facility has put in place a standardized identification tool that includes a hospital patient- record database that shows a patient’s history (Morris & O’Riordan, 2017). This helps in helping nurses assigned a proper understanding of any changes that the patient might have. Overall, these strategies will need the inclusion of others.
Additionally, the facility could incorporate better practices into fall prevention, create a fall prevention team, and train personnel on patient falls. Practices to help better patient handoff during shift changes reduce the risk of patient falls. Caregivers can also learn on practices that help them safeguard themselves to prevent bodily harm while attending to high-risk fall patients. A prevention team that involves personnel from different departments is needed to help in reducing patient fall cases (Morris & O’Riordan, 2017). The team will provide their expertise towards a focus plan of preventing these cases from arising. In the end, caregivers should take patient falls as chances to learn and forecast on how better to help patients who succumb to falls from further aggravating injuries as well as reduce fall cases.
In conclusion, understanding, recognizing and implementing changes improve patient care quality. A concrete analysis of patient fall and factors that lead to it in hospitals helps in constructing a safety improvement plan geared towards better patient care. The incorporation of existing organizational resources while adding on new ideas helps solidify attempts towards curbing patient falls. Patient safety is paramount in healthcare, and as such, it is in everybody's interest to help in improving safety measures that help provide better healthcare.
References
Becker’s Staff. (2020, January 23). 5 Proven Strategies to Prevent Patient Falls: Terri Martin, RN, BSN, MBA, clinical director of Anderson Hospital, shares five strategies that have successfully reduced fall rates at the hospital. Beckershospitalreview.Com. https://www.beckershospitalreview.com/quality/5-proven-strategies-to-prevent-patient-falls.html
Chaneliere, M., Koehler, D., Morlan, T., Berra, J., Colin, C., Dupie, I., & Michel, P. (2018). Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorization of errors in primary care). BMC Family Practice, 19(1). https://doi.org/10.1186/s12875-018-0803-9
Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical Medicine, 17(4), 360–362. https://doi.org/10.7861/clinmedicine.17-4-360
Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk Factors for Falls in Hospital In-Patients: A Prospective Nested Case Control Study. International Journal of Health Policy and Management, 8(5), 300–306. https://doi.org/10.15171/ijhpm.2019.11
PS Net. (2019). Falls. Psnet.Ahrq.Gov. https://psnet.ahrq.gov/primer/falls#:~:text=Epidemiologic%20studies%20have%20found%20that