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 in a health care setting of your choice as well as a safety improvement plan.
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Introduction
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.
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, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.
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 safety quality issue presented in your Assessment Supplement PDF in Assessment 1. 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, provide a rationale for your plan.
Use the Root-Cause Analysis and Improvement Plan [DOCX] Download 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 specific patient safety issue in an organization.
Apply evidence-based and best-practice strategies to address the safety issue.
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
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 but keep in mind that your Assessment 2 will focus on the quality issue you selected in Assessment 1.
Assessment 2 Example [PDF] Download 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 a specific patient safety issue.
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.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address the safety issue.
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a specific patient safety issue in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify organizational resources that could be leveraged to improve your plan.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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Criterion 1
Analyze the root cause of a specific patient safety issue in an organization.
Distinguished
Analyzes the root cause of a specific patient safety issue in an organization, noting the degree to which various elements contributed to the safety issue.
Proficient
Analyzes the root cause of a specific patient safety issue in an organization.
Basic
Identifies the root cause of a specific patient safety issue in an organization.
Non Performance
Does not identify the root cause of a specific patient safety issue in an organization.
Criterion 2
Apply evidence-based and best-practice strategies to address the safety issue.
Distinguished
Applies evidence-based and best-practice strategies to address the safety issue, detailing how the strategies will address the safety issue.
Proficient
Applies evidence-based and best-practice strategies to address the safety issue.
Basic
Describes evidence-based or best-practice strategies to address the safety issue, but their relevance to the safety issue is unclear.
Non Performance
Does not describe evidence-based and best-practice strategies to address the safety issue.
Criterion 3
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Distinguished
Creates a feasible, evidence-based safety improvement plan to address a specific patient safety issue and makes explicit reference to scholarly or professional resources to support the plan.
Proficient
Creates a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Basic
Creates a safety improvement plan to address a specific patient safety issue but lacks appropriate, convincing evidence of its viability.
Non Performance
Does not create a viable, evidence-based safety improvement plan to address a specific patient safety issue.
Criterion 4
Identify existing organizational resources that could be leveraged to improve a safety improvement plan to address a specific patient safety issue.
Distinguished
Identifies existing organizational resources that could be leveraged to improve a safety improvement plan to address a specific patient safety issue, prioritizing them according to potential impact.
Proficient
Identifies existing organizational resources that could be leveraged to improve a safety improvement plan to address a specific patient safety issue.
Basic
Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for a specific patient safety issue are unclear.
Non Performance
Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan to address a specific patient safety issue.
Criterion 5
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Distinguished
Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Proficient
Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Basic
Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling.
Non Performance
Does not organize content for ideas. Lacks logical flow and smooth transitions.
Criterion 6
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Distinguished
Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.
Proficient
Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Basic
Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.
Non Performance
Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.