Root-Cause Analysis and Safety Improvement Plan

/in /by

Home>Homework Answsers>Nursing homework helpNursa year ago02.06.202420Report issuefiles (3)Root-CauseAnalysisandSafetyImprovementPlan.docxAssessment2.docxExemplarAssessment_2.pdfRoot-CauseAnalysisandSafetyImprovementPlan.docx22Root-Cause Analysis and Safety Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, YearRoot-Cause Analysis and Safety Improvement PlanIntroduce 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 CauseDescribe 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 StrategiesIdentity 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 StrategiesProvide 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 ResourcesIdentify 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?ConclusionReferencesReference page should be double spaced throughout without extra spaces between entries.Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.Assessment2.docxFor 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.IntroductionAs 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 ContextNursing 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.ScenarioFor this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.InstructionsThe 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 theRoot-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 butkeep 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 MeasuredBy 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.ExemplarAssessment_2.pdf1Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS-FPX4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, Year2Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanAccording to Spath (2011), root-cause analysis is a methodical approach that aims todiscover the causes of adverse events and near misses for the purpose of identifyingpreventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls ingeropsychiatric patients was conducted at an inpatient mental health unit. The paper describesand analyzes falls and discusses evidence-based strategies to reduce falls and determine asafety improvement plan based on the utilization of existing organizational resources toaddress these falls.Root-Cause Analysis of Falls in Geropsychiatric InpatientsAccording to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control andPrevention reported that falls were a leading cause of unintentional injury death in adultsaged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead toserious head trauma are common among older adults. Injury falls are serious and could leadto fractures, head injury, and intracranial bleed. According to the National Quality Forum(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope etal., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate theirhealth conditions (Powell-Cope et al., 2014).Considering the adverse implications of falls in such patients, a root-cause analysiswas conducted on the 20 cases of falls reported over a period of one year at a geropsychiatricinpatient facility. The aim of the analysis was to understand the causes of falls ingeropsychiatric patients at the unit. The analysis was conducted by a team of five expertsincluding clinicians, supervisors, and quality improvement personnel. The cases reported hadbeen registered by a team of nurses who collated the data related to the falls. All the fallswere described as cases of slipping or tripping, and patients mostly sustained injuriesinvolving pain, mild swelling, and abrasions, with only two of the cases involving minor3Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.fractures. It was also observed that all the falls occurred near the beds of patients and duringthe evening or night shifts when nursing teams were more likely to be understaffed.Geropsychiatric patients are known to be susceptible to falls under the influence ofdrugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in bloodpressure within three minutes of standing), ataxia (lack of voluntary muscular control causedby injury to the central nervous system), and extrapyramidal slowing (impaired motorfunctions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to thesekinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of fallsand noted that in over 50% of the cases, patients had been ambulating under the influence ofdrugs. It was also noted that 80% of the patients who fell while ambulating under theinfluence of drugs had been prescribed zolpidem.At least 40% of the falls could be attributed to generalized weakness, disorientation,and difficulty with mobility. Fall and injury risks are often complicated by behavioralcircumstances such as anger, anxiety, hyperarousal, and the inability to call for help or toremember to call for help. Physical conditions that occur with substance abuse (such asmalnourishment and dehydration) co-exist with psychiatric disability and cause furthercomplications (Powell-Cope et al., 2014).Another factor that plays a role in patient safety is infrastructure in hospitals. This wasparticularly noteworthy as all the falls studied had occurred when patients ambulated neartheir beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskidfootwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,2014).4Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Application of Evidence-Based Strategies to Reduce FallsConsidering that all the falls reported occurred near the patients’ beds, infrastructuralchanges such as the installation of bed- and chair-exit alarms are recommended. Falls frombeds are common in patients with cognitive impairments. Installing electronic alarm systemswas found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,Phillips, Hill, & Dodd, 2014).Strategies such as team engagement and proactive planning to avoid falls can beimplemented in inpatient geropsychiatric wards. Forming a quality and patient safety teamcan serve as an essential safety net and drive a proactive approach rather than a reactive onetoward reducing sentinel events. Such a team could include existing staff in the unit that areselected based on their skills and experience. The primary focus of the team would be toidentify, evaluate, measure, and improve processes and activities related to patient safetywithin the unit (Serino, 2015).Better management of medication must be implemented to reduce falls that occurunder the influence of drugs. Administering melatonin instead of zolpidem reduces the levelof sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroomat night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).Improvement PlanThe improvement plan involves a two-pronged approach: improving staffeffectiveness and coordination and implementing environmental modifications. The first partof the plan focuses on increasing the effectiveness of patient monitoring and staffcoordination through intentional rounding, one-to-one observation of patients, and increasedcommunication among staff. Intentional rounding is a system wherein the nursing staffconduct structured routine checks on patients at regular intervals. The duration of intervals isdecided based on the needs of patients in the unit. Intentional rounding is known to be5Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation isrecommended for high-fall-risk patients. One-to-one observation of patients by moving themclose to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinelevents can be prevented by promoting interdisciplinary collaboration in health care. Goodcommunication and collaboration between physicians, therapists, kinesio therapists, andoccupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).The second part of the improvement plan focuses on environmental modifications toexisting infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alertstaff when a patient attempts to leave the chair or bed has proven to be effective in reducingfalls. These alarms can be attached to the patient directly or to the chair or bed the patientuses (Wong Shee et al., 2014). Other recommended environmental modifications includeusing creative display signage beside patients’ beds. This could be magnets next to the nameof a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Suchdisplays alert staff and visitors of the risk involved with each patient. The use of nonslipstrips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitaryware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patientsafety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained tofacilitate and monitor the use of environmental modifications such as electronic alarms toensure their successful implementation.It is crucial to identify and leverage existing organizational resources whenimplementing the improvement plan. The first part of the improvement plan involvesutilizing the skills and expertise of existing staff members rather than hiring new members toassist in fall prevention. To improve monitoring of patients, the staff members are trained onintentional rounding techniques and one-to-one observation. The environmental interventionssuggested in the second part of the plan involve the installation of additional components to6Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existingresources reduces the overall cost and effort involved in implementing the plan and ensuresminimal disruption to ongoing patient routines and staff-led fall-prevention practices withinthe unit.ConclusionFalls are the leading cause of unintentional injury deaths in geropsychiatric patientsand are largely preventable. A root-cause analysis of falls in such patients was conducted atan inpatient mental health unit. Infrastructural gaps and ambulation under the influence ofdrugs were found to be primary factors that precipitated the falls reported in the unit. Thepaper discusses evidence-based strategies such as medication management, installation ofelectronic alarms, and formation of a quality and patient safety team that would help reducefalls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.The plan involved improving staff effectiveness and coordination and implementingenvironmental modifications.7Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.ReferencesCharles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.(2016). How to perform a root cause analysis for workup and future prevention ofmedical errors: A review. Patient Safety in Surgery, 10.http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016).Intentional rounding: A staff‐led quality improvement intervention in the preventionof patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.http://dx.doi.org/10.1111/jocn.13401Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., …Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mentalhealth units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.https://doi.org/10.1177/1078390314553269Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORNJournal, 102(6), 617–628. https://doi-org.library.capella.edu/10.1016/j.aorn.2015.10.006Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, andeffectiveness of an electronic sensor bed/chair alarm in reducing falls in patients withcognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3),253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8http://dx.doi.org/10.1111/jocn.13401https://doi-org.library.capella.edu/10.1177/1078390314553269http://dx.doi.org/10.1097/NCQ.0000000000000054ExemplarAssessment_2.pdf1Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS-FPX4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, Year2Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanAccording to Spath (2011), root-cause analysis is a methodical approach that aims todiscover the causes of adverse events and near misses for the purpose of identifyingpreventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls ingeropsychiatric patients was conducted at an inpatient mental health unit. The paper describesand analyzes falls and discusses evidence-based strategies to reduce falls and determine asafety improvement plan based on the utilization of existing organizational resources toaddress these falls.Root-Cause Analysis of Falls in Geropsychiatric InpatientsAccording to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control andPrevention reported that falls were a leading cause of unintentional injury death in adultsaged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead toserious head trauma are common among older adults. Injury falls are serious and could leadto fractures, head injury, and intracranial bleed. According to the National Quality Forum(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope etal., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate theirhealth conditions (Powell-Cope et al., 2014).Considering the adverse implications of falls in such patients, a root-cause analysiswas conducted on the 20 cases of falls reported over a period of one year at a geropsychiatricinpatient facility. The aim of the analysis was to understand the causes of falls ingeropsychiatric patients at the unit. The analysis was conducted by a team of five expertsincluding clinicians, supervisors, and quality improvement personnel. The cases reported hadbeen registered by a team of nurses who collated the data related to the falls. All the fallswere described as cases of slipping or tripping, and patients mostly sustained injuriesinvolving pain, mild swelling, and abrasions, with only two of the cases involving minor3Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.fractures. It was also observed that all the falls occurred near the beds of patients and duringthe evening or night shifts when nursing teams were more likely to be understaffed.Geropsychiatric patients are known to be susceptible to falls under the influence ofdrugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in bloodpressure within three minutes of standing), ataxia (lack of voluntary muscular control causedby injury to the central nervous system), and extrapyramidal slowing (impaired motorfunctions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to thesekinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of fallsand noted that in over 50% of the cases, patients had been ambulating under the influence ofdrugs. It was also noted that 80% of the patients who fell while ambulating under theinfluence of drugs had been prescribed zolpidem.At least 40% of the falls could be attributed to generalized weakness, disorientation,and difficulty with mobility. Fall and injury risks are often complicated by behavioralcircumstances such as anger, anxiety, hyperarousal, and the inability to call for help or toremember to call for help. Physical conditions that occur with substance abuse (such asmalnourishment and dehydration) co-exist with psychiatric disability and cause furthercomplications (Powell-Cope et al., 2014).Another factor that plays a role in patient safety is infrastructure in hospitals. This wasparticularly noteworthy as all the falls studied had occurred when patients ambulated neartheir beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskidfootwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,2014).4Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Application of Evidence-Based Strategies to Reduce FallsConsidering that all the falls reported occurred near the patients’ beds, infrastructuralchanges such as the installation of bed- and chair-exit alarms are recommended. Falls frombeds are common in patients with cognitive impairments. Installing electronic alarm systemswas found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,Phillips, Hill, & Dodd, 2014).Strategies such as team engagement and proactive planning to avoid falls can beimplemented in inpatient geropsychiatric wards. Forming a quality and patient safety teamcan serve as an essential safety net and drive a proactive approach rather than a reactive onetoward reducing sentinel events. Such a team could include existing staff in the unit that areselected based on their skills and experience. The primary focus of the team would be toidentify, evaluate, measure, and improve processes and activities related to patient safetywithin the unit (Serino, 2015).Better management of medication must be implemented to reduce falls that occurunder the influence of drugs. Administering melatonin instead of zolpidem reduces the levelof sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroomat night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).Improvement PlanThe improvement plan involves a two-pronged approach: improving staffeffectiveness and coordination and implementing environmental modifications. The first partof the plan focuses on increasing the effectiveness of patient monitoring and staffcoordination through intentional rounding, one-to-one observation of patients, and increasedcommunication among staff. Intentional rounding is a system wherein the nursing staffconduct structured routine checks on patients at regular intervals. The duration of intervals isdecided based on the needs of patients in the unit. Intentional rounding is known to be5Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation isrecommended for high-fall-risk patients. One-to-one observation of patients by moving themclose to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinelevents can be prevented by promoting interdisciplinary collaboration in health care. Goodcommunication and collaboration between physicians, therapists, kinesio therapists, andoccupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).The second part of the improvement plan focuses on environmental modifications toexisting infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alertstaff when a patient attempts to leave the chair or bed has proven to be effective in reducingfalls. These alarms can be attached to the patient directly or to the chair or bed the patientuses (Wong Shee et al., 2014). Other recommended environmental modifications includeusing creative display signage beside patients’ beds. This could be magnets next to the nameof a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Suchdisplays alert staff and visitors of the risk involved with each patient. The use of nonslipstrips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitaryware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patientsafety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained tofacilitate and monitor the use of environmental modifications such as electronic alarms toensure their successful implementation.It is crucial to identify and leverage existing organizational resources whenimplementing the improvement plan. The first part of the improvement plan involvesutilizing the skills and expertise of existing staff members rather than hiring new members toassist in fall prevention. To improve monitoring of patients, the staff members are trained onintentional rounding techniques and one-to-one observation. The environmental interventionssuggested in the second part of the plan involve the installation of additional components to6Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existingresources reduces the overall cost and effort involved in implementing the plan and ensuresminimal disruption to ongoing patient routines and staff-led fall-prevention practices withinthe unit.ConclusionFalls are the leading cause of unintentional injury deaths in geropsychiatric patientsand are largely preventable. A root-cause analysis of falls in such patients was conducted atan inpatient mental health unit. Infrastructural gaps and ambulation under the influence ofdrugs were found to be primary factors that precipitated the falls reported in the unit. Thepaper discusses evidence-based strategies such as medication management, installation ofelectronic alarms, and formation of a quality and patient safety team that would help reducefalls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.The plan involved improving staff effectiveness and coordination and implementingenvironmental modifications.7Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.ReferencesCharles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.(2016). How to perform a root cause analysis for workup and future prevention ofmedical errors: A review. Patient Safety in Surgery, 10.http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016).Intentional rounding: A staff‐led quality improvement intervention in the preventionof patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.http://dx.doi.org/10.1111/jocn.13401Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., …Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mentalhealth units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.https://doi.org/10.1177/1078390314553269Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORNJournal, 102(6), 617–628. https://doi-org.library.capella.edu/10.1016/j.aorn.2015.10.006Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, andeffectiveness of an electronic sensor bed/chair alarm in reducing falls in patients withcognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3),253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8http://dx.doi.org/10.1111/jocn.13401https://doi-org.library.capella.edu/10.1177/1078390314553269http://dx.doi.org/10.1097/NCQ.0000000000000054Root-CauseAnalysisandSafetyImprovementPlan.docx22Root-Cause Analysis and Safety Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, YearRoot-Cause Analysis and Safety Improvement PlanIntroduce 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 CauseDescribe 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 StrategiesIdentity 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 StrategiesProvide 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 ResourcesIdentify 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?ConclusionReferencesReference page should be double spaced throughout without extra spaces between entries.Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.Assessment2.docxFor 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.IntroductionAs 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 ContextNursing 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.ScenarioFor this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.InstructionsThe 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 theRoot-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 butkeep 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 MeasuredBy 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.ExemplarAssessment_2.pdf1Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS-FPX4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, Year2Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanAccording to Spath (2011), root-cause analysis is a methodical approach that aims todiscover the causes of adverse events and near misses for the purpose of identifyingpreventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls ingeropsychiatric patients was conducted at an inpatient mental health unit. The paper describesand analyzes falls and discusses evidence-based strategies to reduce falls and determine asafety improvement plan based on the utilization of existing organizational resources toaddress these falls.Root-Cause Analysis of Falls in Geropsychiatric InpatientsAccording to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control andPrevention reported that falls were a leading cause of unintentional injury death in adultsaged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead toserious head trauma are common among older adults. Injury falls are serious and could leadto fractures, head injury, and intracranial bleed. According to the National Quality Forum(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope etal., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate theirhealth conditions (Powell-Cope et al., 2014).Considering the adverse implications of falls in such patients, a root-cause analysiswas conducted on the 20 cases of falls reported over a period of one year at a geropsychiatricinpatient facility. The aim of the analysis was to understand the causes of falls ingeropsychiatric patients at the unit. The analysis was conducted by a team of five expertsincluding clinicians, supervisors, and quality improvement personnel. The cases reported hadbeen registered by a team of nurses who collated the data related to the falls. All the fallswere described as cases of slipping or tripping, and patients mostly sustained injuriesinvolving pain, mild swelling, and abrasions, with only two of the cases involving minor3Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.fractures. It was also observed that all the falls occurred near the beds of patients and duringthe evening or night shifts when nursing teams were more likely to be understaffed.Geropsychiatric patients are known to be susceptible to falls under the influence ofdrugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in bloodpressure within three minutes of standing), ataxia (lack of voluntary muscular control causedby injury to the central nervous system), and extrapyramidal slowing (impaired motorfunctions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to thesekinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of fallsand noted that in over 50% of the cases, patients had been ambulating under the influence ofdrugs. It was also noted that 80% of the patients who fell while ambulating under theinfluence of drugs had been prescribed zolpidem.At least 40% of the falls could be attributed to generalized weakness, disorientation,and difficulty with mobility. Fall and injury risks are often complicated by behavioralcircumstances such as anger, anxiety, hyperarousal, and the inability to call for help or toremember to call for help. Physical conditions that occur with substance abuse (such asmalnourishment and dehydration) co-exist with psychiatric disability and cause furthercomplications (Powell-Cope et al., 2014).Another factor that plays a role in patient safety is infrastructure in hospitals. This wasparticularly noteworthy as all the falls studied had occurred when patients ambulated neartheir beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskidfootwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,2014).4Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Application of Evidence-Based Strategies to Reduce FallsConsidering that all the falls reported occurred near the patients’ beds, infrastructuralchanges such as the installation of bed- and chair-exit alarms are recommended. Falls frombeds are common in patients with cognitive impairments. Installing electronic alarm systemswas found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,Phillips, Hill, & Dodd, 2014).Strategies such as team engagement and proactive planning to avoid falls can beimplemented in inpatient geropsychiatric wards. Forming a quality and patient safety teamcan serve as an essential safety net and drive a proactive approach rather than a reactive onetoward reducing sentinel events. Such a team could include existing staff in the unit that areselected based on their skills and experience. The primary focus of the team would be toidentify, evaluate, measure, and improve processes and activities related to patient safetywithin the unit (Serino, 2015).Better management of medication must be implemented to reduce falls that occurunder the influence of drugs. Administering melatonin instead of zolpidem reduces the levelof sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroomat night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).Improvement PlanThe improvement plan involves a two-pronged approach: improving staffeffectiveness and coordination and implementing environmental modifications. The first partof the plan focuses on increasing the effectiveness of patient monitoring and staffcoordination through intentional rounding, one-to-one observation of patients, and increasedcommunication among staff. Intentional rounding is a system wherein the nursing staffconduct structured routine checks on patients at regular intervals. The duration of intervals isdecided based on the needs of patients in the unit. Intentional rounding is known to be5Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation isrecommended for high-fall-risk patients. One-to-one observation of patients by moving themclose to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinelevents can be prevented by promoting interdisciplinary collaboration in health care. Goodcommunication and collaboration between physicians, therapists, kinesio therapists, andoccupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).The second part of the improvement plan focuses on environmental modifications toexisting infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alertstaff when a patient attempts to leave the chair or bed has proven to be effective in reducingfalls. These alarms can be attached to the patient directly or to the chair or bed the patientuses (Wong Shee et al., 2014). Other recommended environmental modifications includeusing creative display signage beside patients’ beds. This could be magnets next to the nameof a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Suchdisplays alert staff and visitors of the risk involved with each patient. The use of nonslipstrips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitaryware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patientsafety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained tofacilitate and monitor the use of environmental modifications such as electronic alarms toensure their successful implementation.It is crucial to identify and leverage existing organizational resources whenimplementing the improvement plan. The first part of the improvement plan involvesutilizing the skills and expertise of existing staff members rather than hiring new members toassist in fall prevention. To improve monitoring of patients, the staff members are trained onintentional rounding techniques and one-to-one observation. The environmental interventionssuggested in the second part of the plan involve the installation of additional components to6Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existingresources reduces the overall cost and effort involved in implementing the plan and ensuresminimal disruption to ongoing patient routines and staff-led fall-prevention practices withinthe unit.ConclusionFalls are the leading cause of unintentional injury deaths in geropsychiatric patientsand are largely preventable. A root-cause analysis of falls in such patients was conducted atan inpatient mental health unit. Infrastructural gaps and ambulation under the influence ofdrugs were found to be primary factors that precipitated the falls reported in the unit. Thepaper discusses evidence-based strategies such as medication management, installation ofelectronic alarms, and formation of a quality and patient safety team that would help reducefalls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.The plan involved improving staff effectiveness and coordination and implementingenvironmental modifications.7Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.ReferencesCharles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.(2016). How to perform a root cause analysis for workup and future prevention ofmedical errors: A review. Patient Safety in Surgery, 10.http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016).Intentional rounding: A staff‐led quality improvement intervention in the preventionof patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.http://dx.doi.org/10.1111/jocn.13401Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., …Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mentalhealth units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.https://doi.org/10.1177/1078390314553269Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORNJournal, 102(6), 617–628. https://doi-org.library.capella.edu/10.1016/j.aorn.2015.10.006Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, andeffectiveness of an electronic sensor bed/chair alarm in reducing falls in patients withcognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3),253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8http://dx.doi.org/10.1111/jocn.13401https://doi-org.library.capella.edu/10.1177/1078390314553269http://dx.doi.org/10.1097/NCQ.0000000000000054Root-CauseAnalysisandSafetyImprovementPlan.docx22Root-Cause Analysis and Safety Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, YearRoot-Cause Analysis and Safety Improvement PlanIntroduce 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 CauseDescribe 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 StrategiesIdentity 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 StrategiesProvide 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 ResourcesIdentify 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?ConclusionReferencesReference page should be double spaced throughout without extra spaces between entries.Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.Assessment2.docxFor 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.IntroductionAs 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 ContextNursing 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.ScenarioFor this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.InstructionsThe 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 theRoot-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 butkeep 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 MeasuredBy 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.ExemplarAssessment_2.pdf1Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanYour NameSchool of Nursing and Health Sciences, Capella UniversityNURS-FPX4020: Improving Quality of Care and Patient SafetyInstructor NameMonth, Year2Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Root-Cause Analysis and Improvement PlanAccording to Spath (2011), root-cause analysis is a methodical approach that aims todiscover the causes of adverse events and near misses for the purpose of identifyingpreventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls ingeropsychiatric patients was conducted at an inpatient mental health unit. The paper describesand analyzes falls and discusses evidence-based strategies to reduce falls and determine asafety improvement plan based on the utilization of existing organizational resources toaddress these falls.Root-Cause Analysis of Falls in Geropsychiatric InpatientsAccording to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control andPrevention reported that falls were a leading cause of unintentional injury death in adultsaged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead toserious head trauma are common among older adults. Injury falls are serious and could leadto fractures, head injury, and intracranial bleed. According to the National Quality Forum(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope etal., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate theirhealth conditions (Powell-Cope et al., 2014).Considering the adverse implications of falls in such patients, a root-cause analysiswas conducted on the 20 cases of falls reported over a period of one year at a geropsychiatricinpatient facility. The aim of the analysis was to understand the causes of falls ingeropsychiatric patients at the unit. The analysis was conducted by a team of five expertsincluding clinicians, supervisors, and quality improvement personnel. The cases reported hadbeen registered by a team of nurses who collated the data related to the falls. All the fallswere described as cases of slipping or tripping, and patients mostly sustained injuriesinvolving pain, mild swelling, and abrasions, with only two of the cases involving minor3Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.fractures. It was also observed that all the falls occurred near the beds of patients and duringthe evening or night shifts when nursing teams were more likely to be understaffed.Geropsychiatric patients are known to be susceptible to falls under the influence ofdrugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in bloodpressure within three minutes of standing), ataxia (lack of voluntary muscular control causedby injury to the central nervous system), and extrapyramidal slowing (impaired motorfunctions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to thesekinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of fallsand noted that in over 50% of the cases, patients had been ambulating under the influence ofdrugs. It was also noted that 80% of the patients who fell while ambulating under theinfluence of drugs had been prescribed zolpidem.At least 40% of the falls could be attributed to generalized weakness, disorientation,and difficulty with mobility. Fall and injury risks are often complicated by behavioralcircumstances such as anger, anxiety, hyperarousal, and the inability to call for help or toremember to call for help. Physical conditions that occur with substance abuse (such asmalnourishment and dehydration) co-exist with psychiatric disability and cause furthercomplications (Powell-Cope et al., 2014).Another factor that plays a role in patient safety is infrastructure in hospitals. This wasparticularly noteworthy as all the falls studied had occurred when patients ambulated neartheir beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskidfootwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,2014).4Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.Application of Evidence-Based Strategies to Reduce FallsConsidering that all the falls reported occurred near the patients’ beds, infrastructuralchanges such as the installation of bed- and chair-exit alarms are recommended. Falls frombeds are common in patients with cognitive impairments. Installing electronic alarm systemswas found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,Phillips, Hill, & Dodd, 2014).Strategies such as team engagement and proactive planning to avoid falls can beimplemented in inpatient geropsychiatric wards. Forming a quality and patient safety teamcan serve as an essential safety net and drive a proactive approach rather than a reactive onetoward reducing sentinel events. Such a team could include existing staff in the unit that areselected based on their skills and experience. The primary focus of the team would be toidentify, evaluate, measure, and improve processes and activities related to patient safetywithin the unit (Serino, 2015).Better management of medication must be implemented to reduce falls that occurunder the influence of drugs. Administering melatonin instead of zolpidem reduces the levelof sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroomat night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).Improvement PlanThe improvement plan involves a two-pronged approach: improving staffeffectiveness and coordination and implementing environmental modifications. The first partof the plan focuses on increasing the effectiveness of patient monitoring and staffcoordination through intentional rounding, one-to-one observation of patients, and increasedcommunication among staff. Intentional rounding is a system wherein the nursing staffconduct structured routine checks on patients at regular intervals. The duration of intervals isdecided based on the needs of patients in the unit. Intentional rounding is known to be5Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation isrecommended for high-fall-risk patients. One-to-one observation of patients by moving themclose to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinelevents can be prevented by promoting interdisciplinary collaboration in health care. Goodcommunication and collaboration between physicians, therapists, kinesio therapists, andoccupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).The second part of the improvement plan focuses on environmental modifications toexisting infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alertstaff when a patient attempts to leave the chair or bed has proven to be effective in reducingfalls. These alarms can be attached to the patient directly or to the chair or bed the patientuses (Wong Shee et al., 2014). Other recommended environmental modifications includeusing creative display signage beside patients’ beds. This could be magnets next to the nameof a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Suchdisplays alert staff and visitors of the risk involved with each patient. The use of nonslipstrips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitaryware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patientsafety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained tofacilitate and monitor the use of environmental modifications such as electronic alarms toensure their successful implementation.It is crucial to identify and leverage existing organizational resources whenimplementing the improvement plan. The first part of the improvement plan involvesutilizing the skills and expertise of existing staff members rather than hiring new members toassist in fall prevention. To improve monitoring of patients, the staff members are trained onintentional rounding techniques and one-to-one observation. The environmental interventionssuggested in the second part of the plan involve the installation of additional components to6Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existingresources reduces the overall cost and effort involved in implementing the plan and ensuresminimal disruption to ongoing patient routines and staff-led fall-prevention practices withinthe unit.ConclusionFalls are the leading cause of unintentional injury deaths in geropsychiatric patientsand are largely preventable. A root-cause analysis of falls in such patients was conducted atan inpatient mental health unit. Infrastructural gaps and ambulation under the influence ofdrugs were found to be primary factors that precipitated the falls reported in the unit. Thepaper discusses evidence-based strategies such as medication management, installation ofelectronic alarms, and formation of a quality and patient safety team that would help reducefalls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.The plan involved improving staff effectiveness and coordination and implementingenvironmental modifications.7Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.ReferencesCharles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.(2016). How to perform a root cause analysis for workup and future prevention ofmedical errors: A review. Patient Safety in Surgery, 10.http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016).Intentional rounding: A staff‐led quality improvement intervention in the preventionof patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.http://dx.doi.org/10.1111/jocn.13401Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., …Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mentalhealth units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.https://doi.org/10.1177/1078390314553269Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORNJournal, 102(6), 617–628. https://doi-org.library.capella.edu/10.1016/j.aorn.2015.10.006Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, andeffectiveness of an electronic sensor bed/chair alarm in reducing falls in patients withcognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3),253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8http://dx.doi.org/10.1111/jocn.13401https://doi-org.library.capella.edu/10.1177/1078390314553269http://dx.doi.org/10.1097/NCQ.0000000000000054123Bids(79)Miss DeannaDr. Ellen RMEmily ClareMISS HILLARY A+abdul_rehman_Prof Double RDoctor.NamiraYoung NyanyaSTELLAR GEEK A+ProWritingGuruProf. TOPGRADEDr. Adeline ZoeJahky BDr M. MichelleTutor Cyrus KenDr. Sophie MilesWIZARD_KIMnicohwilliamfirstclass tutorProf SapolskyShow All Bidsother Questions(10)CJS 200 Week 9 Final Project Juvenile Crime PaperBUS-660 Module 8 DQ 2 – Describe the key differences between simulation models and……BUS 210 Week 2 Assignment- Evolution of Business PresentationCase Six: Procter & Gamble – Febreze “Breathe Happy Campaign Launch”Textbook Assignment Comprehensive QuestionsQUESTION 1

It could be argued that the federal and state governments provide an implicit guarantee of hospital borrowings because revenue…Advertisement for a food or beverage productPSY 405 Week 1 – Individual Introduction to Personality PaperFINANCEToday, many companies face budgetary challenges on a continual basis.

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp Order Paper Now