NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

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NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

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.

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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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

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 and Safety Improvement Planning

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 assist 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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

 

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.

 

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 some of the support staff cutting corners or just not really knowing their jobs. I know I’m not supposed to say this, but I have a real problem trusting the CNAs to follow procedures. CNAs or other support staff. They don’t care about patient safety, they don’t respect the safety plan – what there is of it – and they don’t want to take the time to learn the right way of doing things, so they take short cuts so they can get on to their breaks or what have you. I trust the other RNs to do their jobs the right way. The LPNs too, I guess, although a lot of them have been carrying around a lot of bad habits for a long time. But outside of the credentialed nurses? Forget it.

 

There’s this really bad perception out there that skilled nursing facility staff aren’t on the same level as hospital staff. Which makes me crazy! It’s right there in the name, skilled nursing. But then I think of our CNAs here and, well, I see where people are coming from. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

 

Rich Kim

CNA

You know something weird? I’ve been here for three years. That’s not long at all, really. But other CNAs come in and out of here so quickly that I feel like one of the old guard of Clarion Court. It’s a real problem!

 

It means that there are always a lot of people on the floor who are learning on the job. Even if they come in with very good job skills and experience, they still need time to familiarize themselves with Clarion Court itself. If you aren’t familiar with all of the residents, for instance, the older gentleman walking out the door with a firm look like he knows where he’s going may just appear to be a visitor on his way out when he is really a resident eloping. In fact, I think that’s happened here before.

 

Another thing that I think we need to do something about: nursing staff who walk around with their noses up in the air, thinking they’re too good to listen to CNAs when we’ve got something to say. I don’t care how fancy a nursing school you went to for your BSN, we’re all still people with eyes and brains, and we can all see stuff worth hearing about.

 

Lisa Cotrone

LPN

I’ve been here, what, 16 years. Wow! I spent a big chunk of time at Good Shepherd Home in St. Louis Park before that. It’s funny- I feel like I’m part of a dying breed. At least here, seems like all the incoming nurses are RNs, and a good chunk of them have a BSN.

 

Anyway. Safety. We get pulled into meetings, we get lectured about the safety plan, and, well, I don’t know. It’s good, yeah, but it’s words on paper. I’ve been here a long time! I know how to do things safely, no matter what some sheet of paper in a binder says.

 

One thing that happens to me again and again is that there’s this wall blocking communication. We do shift changeovers, and sometimes I have trouble following Fatima from the morning shift. Don’t get me wrong, she’s smart as heck! But she didn’t grow up speaking English, and her accent’s kind of thick. And sometimes the words she uses don’t make sense to me. And asking her to explain doesn’t always clear anything up. Couple of times, this has led to me not knowing something that’s up with a resident that I really should have known. We have charts, of course, and that helps, but charts only get you so far.

 

We get a lot of nurses and CNAs who either aren’t from the U.S. originally or are coming out of recent immigrant communities. I think there’s a couple of reasons for that. Partly because it’s a good entry-level job, and partly because in a lot of those cultures, it’s a definite thing that you should respect and take care of older people. And they see working here, or places like here, as a way to do that. And it’s great! But it means we have this language thing to deal with a lot.

 

 

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?

Root-Cause Analysis and Safety Improvement Plan

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. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis

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.

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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?

Quality and Safety Improvement Plan
Knowledge Base
Root Cause Analysis
Evidence-Based Practice
Sentinel Event
Core Measures
Cost
Effectiveness
Efficiency
Process
Opportunity for Improvement
Performance Improvement Team
QI Toolbox Techniques
Benchmarking
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a) A method of problem solving used for identifying the root causes of faults or problems.
b) The results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life,
which may be positive and appropriate or negative and diminishing.
c) A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations
and, therefore, could be improved.
d)
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The
phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance
of serious adverse outcome.
a) The relationship between the outcomes (results of care) and the resources used to deliver care.
b) The systematic comparison of the products, services, and outcomes of one organization’s outcomes with
regional or national standards. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
c)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
d)
Integrates three basic principles: (1) the best available research evidence bearing on whether and why a
treatment works, (2) clinical expertise (clinical judgment and experience) to rapidly identify each patient’s
unique health state and diagnosis, their individual risks and benefits of potential interventions, and (3) client
preferences and values.
a) The interrelated activities of healthcare organizations-including governance, managerial support, and clinical
services-that affect patient outcomes across departments and disciplines within an integrated environment.
b) A method of problem solving used for identifying the root causes of faults or problems.
c) Tools that facilitate the collection, display, and analysis of data and information and that help team members
stay focused, including cause-and-effect diagrams, graphic presentations, and others.
d)
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The
phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance
of serious adverse outcome.
a) The systematic comparison of the products, services, and outcomes of one organization’s outcomes with
regional or national standards.
b)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
c) Tools that facilitate the collection, display, and analysis of data and information and that help team members
stay focused, including cause-and-effect diagrams, graphic presentations, and others.
d) The relationship between the outcomes (results of care) and the resources used to deliver care.
a) The results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life,
which may be positive and appropriate or negative and diminishing.
b) The amount of financial resources consumed in the provision of healthcare services.
c) A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations
and, therefore, could be improved.
d) The relationship between the outcomes (results of care) and the resources used to deliver care.
a)
Integrates three basic principles: (1) the best available research evidence bearing on whether and why a
treatment works, (2) clinical expertise (clinical judgment and experience) to rapidly identify each patient’s
unique health state and diagnosis, their individual risks and benefits of potential interventions, and (3) client
preferences and values.
b) The interrelated activities of healthcare organizations-including governance, managerial support, and clinical
services-that affect patient outcomes across departments and disciplines within an integrated environment.
c) The degree to which care is provided in the correct manner, given the current state of knowledge, to achieve
the desired or projected outcome(s) for the individual.
d) The relationship between the outcomes (results of care) and the resources used to deliver care
a) The amount of financial resources consumed in the provision of healthcare services.
b) The relationship between the outcomes (results of care) and the resources used to deliver care.
c) The degree to which care is provided in the correct manner, given the current state of knowledge, to achieve
the desired or projected outcome(s) for the individual. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis
d) The results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life,
which may be positive and appropriate or negative and diminishing.
a)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
b) The systematic comparison of the products, services, and outcomes of one organization’s outcomes with
regional or national standards.
c) A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations
and, therefore, could be improved
d) The interrelated activities of healthcare organizations-including governance, managerial support, and clinical
services-that affect patient outcomes across departments and disciplines within an integrated environment.
a) A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations
and, therefore, could be improved.
b) The results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life,
which may be positive and appropriate or negative and diminishing.
c) Tools that facilitate the collection, display, and analysis of data and information and that help team members
stay focused, including cause-and-effect diagrams, graphic presentations, and others.
d) Members of the healthcare organization who have formed a functional or cross-functional group to examine a
performance issue and make recommendations with respect to its improvement.
a) A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations
and, therefore, could be improved.
b) Members of the healthcare organization who have formed a functional or cross-functional group to examine a
performance issue and make recommendations with respect to its improvement.
c)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
d) Tools that facilitate the collection, display, and analysis of data and information and that help team members
stay focused, including cause-and-effect diagrams, graphic presentations, and others.
a) The systematic comparison of the products, services, and outcomes of one organization’s outcomes with
regional or national standards.
b) The interrelated activities of healthcare organizations-including governance, managerial support, and clinical
services-that affect patient outcomes across departments and disciplines within an integrated environment.
c) Tools that facilitate the collection, display, and analysis of data and information and that help team members
stay focused, including cause-and-effect diagrams, graphic presentations, and others.
d)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
a)
Sets of patient care characteristics that The Joint Commission (TJC) and Centers for Medicare & Medicaid
Services (CMS) have determined to reflect the quality of care an organization can provide for important
diagnoses.
b) The degree to which care is provided in the correct manner, given the current state of knowledge, to achieve
the desired or projected outcome(s) for the individual.
c) The results of care, treatment, and services in terms of the patient’s expectations, needs, and quality of life,
which may be positive and appropriate or negative and diminishing.
d) The systematic comparison of the products, services, and outcomes of one organization’s outcomes with
regional or national standards. NURS FPX4020 Medical Errors in A Vila Health Root Cause Analysis