NURS FPX 4020 Capella Resource Toolkit Safety Improvement Initiative Bibliography

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NURS FPX 4020

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For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.

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Assessment 4 Instructions: Improvement Plan Tool Kit For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan. Communication in the health care environment consists of an information-sharing experience whether through oral or written messages (Chard, Makary, 2015). As health care organizations and nurses strive to create a culture of safety and quality care, the importance of interprofessional collaboration, the development of tool kits, and the use of wikis become more relevant and vital. In addition to the dissemination of information and evidence-based findings and the development of tool kits, continuous support for and availability of such resources are critical. Among the most popular methods to promote ongoing dialogue and information sharing are blogs, wikis, websites, and social media. Nurses know how to support people in time of need or crisis and how to support one another in the workplace; wikis in particular enable nurses to continue that support beyond the work environment. Here they can be free to share their unique perspectives, educate others, and promote health care wellness at local and global levels (Kaminski, 2016). You are encouraged to complete the Determining the Relevance and Usefulness of Resources activity prior to developing the repository. This activity will help you determine which resources or research will be most relevant to address a particular need. This may be useful as you consider how to explain the purpose and relevance of the resources you are assembling for your tool kit. The activity is for your own practice and self-assessment, and demonstrates course engagement. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: • Competency 1: Analyze the elements of a successful quality improvement initiative. • • • • • • • • Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Competency 2: Analyze factors that lead to patient safety risks. Analyze the value of resources to reduce patient safety risk or improve quality with medication administration. Competency 3: Identify organizational interventions to promote patient safety. Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. Present compelling reasons and relevant situations for resource tool kit to be used by its target audience. Communicate in a clear, logically structured, and professional manner, using current APA style and formatting. References Chard, R., Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329-342. Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1-7. Professional Context Nurses are often asked to implement processes, concepts, or practices - sometimes with little preparatory communication or education. One way to encourage sustainability of quality and process improvements is to assemble an accessible, user-friendly tool kit for knowledge and process documentation. Creating a resource repository or tool kit is also an excellent way to follow up an educational or inservice session, as it can help to reinforce attendees' new knowledge as well as the understanding of its value. By practicing creating a simple online tool kit, you can develop valuable technology skills to improve your competence and efficacy. This technology is easy to use, and resources are available to guide you. Scenario For this assessment, consider taking one of these two approaches: 1. Build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan pertaining to medication administration and put the plan into action. 2. Locate a safety improvement plan (your current organization, the Institution for Healthcare Improvement, or a publicly available safety improvement initiative) pertaining to medication administration and create an online tool kit or resource repository that will help an audience understand the research behind the safety improvement plan and how to put the plan into action. Preparation Google Sites is recommended for this assessment - the tools are free to use and should offer you a blend of flexibility and simplicity as you create your online tool kit. Please note that this requires a Google account; use your Gmail or GoogleDocs login, or create an account following the directions under the "Create Account" menu. Refer to the following links to help you get started with Google Sites: • • • G Suite Learning Center. (n.d.). Get started with Sites. Retrieved from https://gsuite.google.com/learning-center/products/sites/get-started/#!/ Google. (n.d.). ;Google Sites. Retrieved from https://sites.google.com Google. (n.d.). ;Sites help. Retrieved from https://support.google.com/sites/?hl=en#topic= Instructions Using Google Sites, assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed. It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an ;initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues. Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include ;the following: • • • • An APA-formatted citation of the resource with a working link. A description of the information, skills, or tools provided by the resource. A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration. A description of how nurses can use this resource and when its use may be appropriate. Remember that you must make your site public so that your faculty can access it. Check out the Google Sites resources for more information. Here is an example entry: • • • • • • • Merret, A., Thomas, P., Stephens, A., ;Moghabghab, R., Gruneir, M. (2011). A collaborative approach to fall prevention. Canadian Nurse, 107(8), 24-29. Retrieved from www.canadian-nurse.com/articles/issues/2011/october-2011/acollaborative-ap This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting. 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. Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration. Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on medication administration. Analyze the value of resources to reduce patient safety risk related to medication administration. Present compelling reasons and relevant situations for use of resource tool kit by its target audience. Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting. • Example Assessment: You may use the following example 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 tool kit will focus on promoting safety with medication administration. Note that you do not have to submit your bibliography in addition to the Google Site; the example bibliography is merely for your reference. Assessment 4 Example [PDF]. To submit your online tool kit assessment, paste the link to your Google Site in the assessment submission box. Example Google Site: You may use the example Google Site, Resources for Safety and Improvement Measures in Geropsychiatric Care, to give you an idea of what a Proficient or higher rating on the scoring guide would look like for this assessment but keep in mind that your tool kit will focus on promoting safety with medication administration. Note: If you experience technical or other challenges in completing this assessment, please contact your faculty member. Additional Requirements • APA formatting: References and citations are formatted according to current APA style Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course. Running head: IMPROVEMENT PLAN TOOL KIT Improvement Plan Tool Kit Learner’s Name Capella University Improving Quality of Care and Patient Safety Improvement Plan Tool Kit April, 2019 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 1 IMPROVEMENT PLAN TOOL KIT 2 Improvement Plan Tool Kit This improvement plan tool kit aims to enable nurses to implement and sustain safety improvement measures in health care settings in a geropsychiatric unit. The tool kit has been organized into four categories with three annotated sources each. The categories are as follows: general organizational safety and quality best practices, environmental safety and quality risks, staff-led preventive strategies, and best practices for reporting and improving environmental safety issues. Annotated Bibliography General Organizational Safety and Quality Best Practices Sherwood, G., & Horton-Deutsch, S. (2015). Reflective organizations: On the front lines of QSEN and reflective practice implementation. Retrieved from https://ebookcentralproquest-com.library.capella.edu/lib/capella/detail.action?docID=3440207# This e-book presents the paradigm shift required for organizations to provide QSEN (quality and safety education to nurses). It provides readers with the innovative pedagogical approaches required to change traditional content-based health care education methods to interactive methods that engage learners. These approaches include facilitative teaching, visual thinking strategies, creating a presence that is authentic, and meaningful learning through debriefing. Concrete examples in the resource demonstrate the application of reflective learning. Additionally, the reflective questions in the resource guide readers to evaluate their own practice, either independently or in groups, to implement formal education programs with a focus on self-improvement. The resource prepares nursing students for advanced competency, Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 3 which will help them adopt reflective thinking, develop a safety culture, and therefore qualitatively improve practices in critical health units such as geropsychiatry units. Fleiszer, A. R., Semenic, S. E., Ritchie, J. A., Richer, M.-C., & Denis, J.-L. (2016). A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study. International Journal of Nursing Studies, 53, 204–218. https://doi.org/10.1016/j.ijnurstu.2015.09.004 This article helps analyze the sustainability of a best practice guidelines program implemented in acute health care settings. The sustainability of the program was characterized by the following: benefits for patients as the rate of incidence of falls reduced; routinization of best practices as the team’s adherence to guidelines improved; and, in the long term, the development of the team’s adaptability to changes in circumstances that threatened the program. Seven key factors that accounted for the sustainability of the program were also identified. The source explains how relationships between the characteristics of sustainability (benefits, routinization, and development) and the seven key factors contributed toward the sustainability of the improvement program. This source is valuable for nursing students as it helps them understand how safety programs can be sustained to ensure the long-term reduction of the incidence of sentinel events in geropsychiatric units. Kossaify, A., Hleihel, W., & Lahoud, J.-C. (2017). Team-based efforts to improve quality of care, the fundamental role of ethics, and the responsibility of health managers: Monitoring and management strategies to enhance teamwork. Public Health, 153, 91–98. https://doi.org/10.1016/j.puhe.2017.08.007 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 4 This paper discusses the benefits of teamwork in improving the quality of health care. It presents a review of 33 papers identified after performing a search on PubMed. The paper discusses the important ingredients of efficient teamwork such as self-awareness and the individual behavior of team members, the ethical climate within the team, the work environment and institutional infrastructure, positive moderation from leadership, and communication and coordination among team members. Effective teamwork can help reduce the incidence of sentinel events that result from preventable medical errors, which are often caused by dysfunctional communication among team members. Teamwork is more reliable and efficient than individual work in high-risk environments such as a geropsychiatry unit. Although the specific contexts of readers’ practices may be different, this resource is valuable for nursing administrators and professionals as it discusses the implementation of values needed for positive teamwork as well as the monitoring and management of teamwork. Environmental Safety and Quality Risks Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339. https://doi.org/10.1177/1078390314553269 This source mentions a study conducted to analyze falls in geropsychiatric patients. The study also focused on selling falls prevention in psychiatric units. The risk factors that lead to the falls were identified by a focus group. The focus group formulated an improvement plan to reduce the number of falls, and it was found that implementing Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 5 infrastructural changes such as the use of geriatric-friendly sanitary ware such as raised toilet seats helped reduce the rate of incidence of falls. Although all the changes may not be feasible in a given setup, many of the strategies mentioned in this study could serve as a starting point for the prevention of falls. The article helps nursing students understand the challenges that occur in an adult mental health unit and the quality improvement measures taken to resolve these challenges. Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253– 262. https://doi.org/10.1097/NCQ.0000000000000054 This source is a preliminary study conducted to determine the effectiveness of electronic sensor bed/chair alarms to reduce the occurrence of falls in patients with cognitive impairment. These alarms can be attached to the patient’s body or to the bed/chair the patient uses to alert the nursing staff every time the patients move or leave their seat. Nurses were educated about the alarms and asked to document their observations and provide feedback. Although effective at preventing falls in patients with cognitive impairment, the electronic sensors needed improvements such as the elimination of cords that may be hazardous to patients and the additional provision of alerting nurses through pagers. This source helps nursing students understand both the effectiveness and the limitations of electronic sensor alarms in reducing the occurrence of falls. Chari, S. R., Smith, S., Mudge, A., Black, A. A., Figueiro, M., Ahmed, M., . . . Haines, T. P. (2016). Feasibility of a stepped wedge cluster RCT and concurrent observational subCopyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 6 study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial. Pilot and Feasibility Studies, 2(1). https://doi.org/10.1186/s40814-015-0043-x Inadequate lighting at night in geropsychiatric wards is one of the important causes of falls in geropsychiatric units. Psychotropic medications can cause cognitive impairments and blurring of vision, which can be aggravated by dim lighting in the units. The article presents a trial pilot study conducted to evaluate the effects of the use of modified night lighting in inpatient wards to prevent falls. LED lights were installed in the vicinity of the beds and the toilets, where falls were likely to occur. The study provides valuable insights that could inform design and refurbishment efforts at geropsychiatric units. An important limitation of the study is that a stepped wedge, cluster randomized controlled trial has not yet been applied to test environmental modifications in any setting. However, the modifications discussed could still be implemented as an important intervention strategy for preventing falls in older adults with cognitive impairment. Staff-Led Preventive Strategies Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff‐led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1–2), 115–124. https://doi.org/10.1111/jocn.13401 This article highlights an intervention strategy called intentional rounding to reduce the occurrence of inpatient falls. Intentional rounding is a specific strategy in which nurses conduct a routine check on patients at certain time intervals based on the needs of the Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 7 patient. The rounding was implemented through effective communication and teamwork among the nursing staff and iterations of plan-do-check-act measures. This proactive staff-led strategy helped reduce the rate of falls by 50%. This study achieved success through the combined efforts of the research team that conducted the analysis of the system to design the rounding format and the frontline nursing staff who conducted the intentional rounds. Although its sample size was small and not entirely representative, the study does establish intentional rounding as an effective falls-prevention strategy, which when implemented with adequate staff engagement and support from leadership definitively reduces the occurrence of falls. Moncada, L. V. V., & Mire, G. L. (2017). Preventing falls in older persons. Am Fam Physician, 96(4), 240–247. Retrieved from https://www.aafp.org/afp/2017/0815/p240.pdf The article posits that a history of falls in older persons is associated with an increased risk of a future fall. The American Geriatrics Society recommends that older adults aged 65 and above should undergo annual screening for balance impairment and a history of falls as a preliminary intervention for the prevention of falls. The article also highlights an algorithm developed by the Centers for Disease Control and Prevention. The algorithm suggests assessment and multifactorial interventions to prevent falls in patients who have had more than two falls and more than one fall-related injury. The multifactorial interventions include exercise routines that include balance and gait training, the use of vitamin D supplements with or without calcium based on the community in which the patients dwell, and the management of psychotropic medication. These interventions have been known to cause a significant decrease in the rate of falls Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 8 and can be implemented across all geropsychiatric wards to prevent sentinel events. The source is authentic and hence can be referred to by nursing students to understand multifactorial interventions in the prevention of falls. Isaac, L. M., Buggy, E., Sharma, A., Karberis, A., Maddock, K. M., & Weston, K. M. (2018). Enhancing hospital care of patients with cognitive impairment. International Journal of Health Care Quality Assurance, 31(2), 173–186. https://doi.org/10.1108/IJHCQA-112016-0173 This paper evaluates the TOP5 intervention strategy of improving patient care. The strategy involves engaging with carers of geriatric patients (individuals who are family members or friends of the patients) to collect characteristic non-clinical information about patients to personalize care and reduce falls. The carers of patients narrated to the nursing staff five important and distinct characteristic details such as the patients’ needs and past emotional experiences. The nursing staff then prepared a customized plan of care for each patient based on this information. This study reported a significant reduction in falls and qualitatively improved care. The study enables nursing students to meaningfully involve the carers of cognitively impaired patients and reduce the incidence of falls. Best Practices for Reporting and Improving Environmental Safety Issues Tan, A. K. (2015). Emphasizing caring components in nurse-patient-nurse bedside reporting. International Journal of Caring Sciences, 8(1), 188–193. Retrieved from https://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1648623547%3Faccountid=27965 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 9 This source provides a review of strategies that improve bedside reporting and transfer of duties after a change of shift among nursing staff. The source also emphasizes team engagement that can help reduce the incidence of sentinel events, especially in health care units such as geropsychiatry units. Bedside reporting is a vital concern in geropsychiatric units as patients are prone to behavioral changes and unpredictable behavior may affect other patients in the unit. During a shift change, the nursing staff can alert the incoming staff about the condition of such patients to proactively prepare the staff to address any forthcoming issue. Barriers to bedside reporting were also analyzed, and barriers perceived by patients and those perceived by nurses were identified. These barriers can be eliminated through open communication and by educating the nursing staff. The article provides a valuable discussion of factors that influence bedside reporting such as patient-centered care philosophy, guidelines of the Joint Commission Institute, demand for patient participation in making health care decisions, and the shortcomings of traditional handover practices. Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117–1127. https://doi.org/10.1007/s40264-016-0455-4 This article highlights the severity of underreporting of adverse drug events. An adverse drug event is defined by the World Health Organization as “a response to a medicine which is noxious and unintended, and which occurs at doses normally used in man.” Adverse drug events are estimated to cause 7,000 deaths across health care settings in the United States each year. It is also said that half of these adverse drug events result from Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 10 preventable medication errors. The article also identifies factors that lead to the underreporting of the adverse drug events such as lack of training among health care professionals and standardized reporting processes. Underreporting of adverse drug events can be a critical problem, especially in health care units such as geropsychiatry units. Individual patients may react differently to psychotropic drugs; reactions may include overdoses or allergic reactions. These reactions need to be monitored closely and reported efficiently to avoid complications including falls. Nursing students can understand the importance of reporting adverse drug events through this source. Lozito, M., Whiteman, K., Swanson-Biearman, B., Barkhymer, M., & Stephens, K. (2018). Good catch campaign: Improving the perioperative culture of safety. AORN Journal, 107(6), 705–714. https://doi.org/10.1002/aorn.12148 This article provides evidence-based results to show that the culture of safety in a perioperative unit was improved after implementing the good catch campaign. Good catch is the ability of nursing staff to point out mistakes and report them to avoid sentinel events. The campaign described in the article involves implementing a standardized electronic reporting system and debriefing process. The nursing staff discusses the plan of care for each patient at the end of the day during debriefing. This helps the nursing staff note characteristic risks involved with each patient and provide better care. Training nursing staff to implement the good catch campaign in health care units such as geropsychiatry units should enable the effective reporting of factors that could cause falls with a view to avoid them. This source enables nursing students to implement electronic reporting systems to report good catches and thereby reduce falls. Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 11 References Chari, S. R., Smith, S., Mudge, A., Black, A. A., Figueiro, M., Ahmed, M., . . . Haines, T. P. (2016). Feasibility of a stepped wedge cluster RCT and concurrent observational substudy to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial. Pilot and Feasibility Studies, 2(1). https://doi.org/10.1186/s40814-015-0043-x Fleiszer, A. R., Semenic, S. E., Ritchie, J. A., Richer, M.-C., & Denis, J.-L. (2016). A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study. International Journal of Nursing Studies, 53, 204– 218. https://doi.org/10.1016/j.ijnurstu.2015.09.004 Isaac, L. M., Buggy, E., Sharma, A., Karberis, A., Maddock, K. M., & Weston, K. M. (2018). Enhancing hospital care of patients with cognitive impairment. International Journal of Health Care Quality Assurance, 31(2), 173–186. https://doi.org/10.1108/IJHCQA-112016-0173 Kossaify, A., Hleihel, W., & Lahoud, J.-C. (2017). Team-based efforts to improve quality of care, the fundamental role of ethics, and the responsibility of health managers: Monitoring and management strategies to enhance teamwork. Public Health, 153, 91–98. https://doi.org/10.1016/j.puhe.2017.08.007 Lozito, M., Whiteman, K., Swanson-Biearman, B., Barkhymer, M., & Stephens, K. (2018). Good catch campaign: Improving the perioperative culture of safety. AORN Journal, 107(6), 705–714. https://doi.org/10.1002/aorn.12148 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 12 Moncada, L. V. V., & Mire, G. L. (2017). Preventing falls in older persons. Am Fam Physician, 96(4), 240–247. Retrieved from https://www.aafp.org/afp/2017/0815/p240.pdf Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff‐led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1–2), 115–124. https://doi.org/10.1111/jocn.13401 Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339. https://doi.org/10.1177/1078390314553269 Sherwood, G., & Horton-Deutsch, S. (2015). Reflective organizations: On the front lines of QSEN and reflective practice implementation. Retrieved from https://ebookcentralproquest-com.library.capella.edu/lib/capella/detail.action?docID=3440207# Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117–1127. https://doi.org/10.1007/s40264-016-0455-4 Tan, A. K. (2015). Emphasizing caring components in nurse-patient-nurse bedside reporting. International Journal of Caring Sciences, 8(1), 188–193. Retrieved from https://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1648623547%3Faccountid=27965 Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 13 cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253– 262. https://doi.org/10.1097/NCQ.0000000000000054 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. Running head: ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis and Safety Improvement Plan Yailin Mur Fernandez NURS-FPX4020 Capella University October, 2020 1 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 2 Root-Cause Analysis and Safety Improvement Plan Nurses play a central role in addressing quality improvement in healthcare and one of the approaches is through identifying root-causes of medication errors and proposing methods of addressing them. The incident of concern is a medication error whereby the nurse administered the wrong dosage to a patient leading to temporary harm. This error occurred in a large urban hospital in the medical wards. The event triggered the need for a root-cause analysis of the factors leading to wrong dosage. This paper presents a root-cause analysis of the event, discusses some evidence-based and best-practice strategies to address it, and proposes a safety improvement plan to address the root-causes with the support of the available organizational resources. Analysis of Root-Cause The identified event is a medication error whose root cause could be one or more factors. Medication errors are common the health care industry and they cause harm and death to numerous patients each year. Medication errors cause adverse drug events and every year, 5% of patients in the hospital experience an adverse drug event (Giardina et al., 2018). In addition to adverse drug events, medication errors generally reduce the quality of care and safety of patients hence affecting the reputation of the organization. Some events may attract litigation against the health care organization and the nurse involved and hence medication errors are costly. The incident described in the introduction led to an overdose of the prescribed drug leading to poor health outcomes and extended hospital stay. The event was detected by another nurse when the patient started exhibiting symptoms of drug overdose. A review of the patient records showed that the attending nurse had administered two times the required dose. The patient developed ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 3 acute confusion, anxiety, and hyperventilation. The event can be related to human error and systems failure and hence this analysis seeks to correct these two categories of causal factors. The incident was investigated by a team of four, including the nurse manager, charge nurse, quality manager, and attending physician. The review of patient records revealed that the indicated dosage in the prescriptions was doubled in the nurse’s entry of the administered dosage. Therefore, the nurse administered the wrong dosage and entered in the patient records. This overview presented an opportunity to discuss the issue with the involved nurse. The nurse stated that the error occurred as a genuine mistake and there must have been some confusion. The analysis then included environmental and system factors. An overview of medication errors and the organizational environment shows that the error can be attributed to high nurse workload and burnout. A review of the medical ward showed that there was a serious shortage of staffing hence nurses handled more acuity than they should. According to Johnson et al. (2017), a leading cause of medication errors is nurse burnout and distraction. In this case, a high workload for the nurse led to confusion of the medication dosage. Distractions also occur when the nurse is interrupted when in the process of medication preparation and administration. Staff workload led to low concentration in the process of medication administration and resulted in the medication error. Another cause of medication errors such as the identified incident is the standard processes implemented in the health unit. Systemic medication errors are those caused by the design of the system as well as equipment and technology used. The medication administration process allows nurses to prepare medication at the patient’s bedside. Bedside medication preparation presents inherent risks in nurse distraction by the patient, other patients in the ward, and other staff. In general, the stated event was caused by human error contributed by workload ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 4 and distractions as well as the standard processes of medication administration in the medical ward. Application of Evidence-Based Strategies Medication errors have been linked to both interruptions and nurse workload. A study conducted in Australia showed that 99% of all medication events had interruptions (Johnson et al., 2017). These interruptions were mostly from other nurses and often non-care related. The frequency of interruptions was associated with procedural failures and clinical errors. Similarly, research showed that as nurse-patient-ratio increases, there is a decrease in quality of care and number of medication errors related to nursing workload (Qureshi et al., 2017). These causes of medication error show the need for interventions to reduce distractions and nurse workload. The proposed strategies will address these two root causes. Various strategies may be used to reduce nurse distractions and workload. First, distractions and interruptions may be reduced through design of a process to ensure that nurses are not interrupted during the medication preparation process. This process will ensure that nurses can acquire a private space where they can prepare medication away from the patient’s bedside and then go to the patient for administration. Regarding nurse workload and process for medication administration, staffing and nurse training could be implemented to reduce workload and increase the competence of nurses in offering care. The two proposed strategies can be consolidated into a safety improvement plan using the existing organizational resources to improve patient safety by limiting medication administration errors. Safety Improvement Plan The proposed improvement plan presents two major approaches to the medication administration challenge. The first approach is to implement the ‘sterile cockpit’ concept to the ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 5 process of medication preparation to reduce nurse interruptions. This concept is borrowed from the aviation industry whereby nonessential activities are eliminated from the cockpit during critical phases of the flight (Ruby, 2016). Applied to medication administration, this strategy avails a safe space for nurses to go and prepare medications away from all nonessential activities. Previous research shows that the strategy led to 42% reduction in medication errors (Ruby, 2016). The objective of this strategy is to limit interruptions as much as possible and create an environment where the nurse can concentrate on the crucial task at hand. This strategy will be implemented by creating a medication preparation room whereby nurses will only be allowed if they are carrying out this specific activity and interactions will be kept at minimum. The second strategy to be used for this root cause is to implement staff recruitment and training in reducing medication errors. Since staffing levels have been established as low in the organization and contribute to medication errors, increasing the number of staff in the organization can effectively reduce the number of errors. Regular staff awareness and training in patient safety have also been established as causing a significant decrease in the rates of medication errors (Di Simone et al., 2018). This strategy thus aims to increase the number of competent nurses to reduce human error emanating from knowledge deficit. Wrong dosage could emanate from the nurse’s inexperience and lack of knowledge in the medication administration processes. In this case, therefore, the intervention will reduce the risk of such errors by increasing nursing staff knowledge and competence. Existing Organizational Resources Implementation of the proposed strategies relies on leveraging existing resources to produce the best results. The timeline for this improvement plan includes the initial investment in the sterile cockpit and staffing needs as well as ongoing training of all nurses to enhance care ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 6 quality. The safe space for medication preparation will be designated in a room adjacent to the medical ward where nurses can retreat and prepare medications without interruptions. The hospital facility has that space and furnishing and equipment are the required resources. Secondly, the organization needs financial investment in recruiting new staff and training existing ones. Financial investment in a recruitment program is required whereby the actual number of nurses and their qualifications are to be determined. An available resource is the experience of many charge nurses and nurse managers who can train the existing nurses and new recruits on patient safety and reduction of medication error risks. Overall, the organization has the financial and training capacity to implement both strategies of the improvement plan. Conclusion Medication errors are common occurrences causing adverse events and near misses in the health care industry. The described medication administration error is attributed to human error and systemic challenges in the medication administration process. The proposed strategy will address staff distractions by providing a private space where nurses can concentrate on medication preparation before administration. Moreover, staffing levels will be improved to reduce the risk of errors made due to high staff workload and burnout. Leveraging the existing organizational resources, the program will effectively address the current medication administration error and prevent similar and related errors in the future. ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 7 References Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 22(5), 346. https://doi.org/10.4103/ijccm.IJCCM_63_18 Giardina, C., Cutroneo, P. M., Mocciaro, E., Russo, G. T., Mandraffino, G., Basile, G., ... & Arcoraci, V. (2018). Adverse drug reactions in hospitalized patients: results of the FORWARD (facilitation of reporting in hospital ward) study. Frontiers in Pharmacology, 9, 350. https://doi.org/10.3389/fphar.2018.00350 Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., ... & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7), 498-507. https://doi.org/10.1111/jonm.12486 Qureshi, S. M., Purdy, N., Mohani, A., & Neumann, W. P. (2019). Predicting the effect of nurse– patient ratio on nurse workload and care quality using discrete event simulation. Journal of Nursing Management, 27(5), 971-980. https://doi.org/10.1111/jonm.12757 Ruby, Z. C. (2016). Simple steps to reduce medication errors. Nursing, 46(8), 63-65. https://www.nursingcenter.com/journalarticle?Article_ID=3603336&Journal_ID=54016 &Issue_ ID=3603170 YAILIN MUR FERNANDEZ NURS-FPX4020 OCTOBER, 2020  Increase in medication error rates  The nurse is central in reducing errors  Agenda 1. Identify a safety improvement plan by increasing accuracy in medication administration, 2. Define the role of nurses in the safety improvement process 3. Highlight major changes on care processes 1. Increased awareness of medication errors & their occurrence 2. Competence in implementing safety improvement program 3. Awareness of relevant changes for safety improvement  Problem focus: An increase in medication administration errors in the past  Intervention: sterile cockpit concept providing safe space for preparing medication to reduce interruptions (Ruby, 2016)  Strategy: A medication preparation room to reduce interruptions  Objective: create environment where nurses focus on task at hand  Nurses are often busy due to workload  Interruptions increase risk of medication administration errors  Safe space for medication preparation  Reduced errors enhance patient safety & care quality  Learn and understand new processes  Adherence to new processes  Aligning plan with care & nursing routines  Ensure new processes fit in our service provision 1. Nurses are in direct contact with patients- affect quality of care 2. Most medication errors involve nurses (Kavanagh, 2017) 3. Safety & quality improvement benefit nurses through job satisfaction & reduced risk of litigation  Two major changes: 1. Staff training in the new processes- carried out by nurse leaders 2. Implementation in everyday administration processes- requires change in medication preparation process 1. Check MAR against physician order 2. Perform 5 rights of medication administration 3. Check labels & compare with MAR 4. After pouring, circle in MAR 5. Go to patient, confirm identity, administer 6. Post-assessment & signing MAR (Martyn, Paliadelis, & Perry, 2019)  Surveys before and after implementation Determine whether there are effective changes in medication administration  Open communication policy Interviews and suggestion box for nurses to provide feedback on the program 1. Assess program effectiveness to determine whether to continue or discontinue 2. Areas of improvement to strengthen program for better outcomes 3. Determine changes in the workplace to enhance safety & quality  Nurses should actively participate in improvement plan  New medication administration protocol in the program  Nurses should participate since it directly affects them  Plan will improve safety, quality, & job satisfaction  Ruby, Z. C. (2016). Simple steps to reduce medication errors. Nursing, 46(8), 63-65.  Kavanagh, C. (2017). Medication governance: preventing errors and promoting patient safety. British Journal of Nursing, 26(3), 159-165.  Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviours beyond the five-rights. Nurse Education in Practice, 37, 109-114.
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Running Head: RESOURCE TOOLKIT

1

Resource Toolkit: Safety Improvement Initiative
Name
Institution
Date

RESOURCE TOOLKIT

2

Resource Toolkit: Safety Improvement initiative
In this toolkit, various resources have been described and evaluated with the focus of providing a
resource toolkit that enables therapists and other healthcare providers to apply and maintain
safety enhancement measures, as discussed in the next topic in this paper. Therefore, 12
annotated scholarly resources have been used to describe four major categories. Three
professional resources have been used for each theme.
Annotated Bibliography
General Organizational Safety and Quality Best Practices
De Moissac, D., & Bowen, S. (2019). Impact of language barriers on quality of care and patient
safety for official language minority Francophones in Canada. Journal of Patient
Experience, 6(1), 24-32.
This article helps with the understanding of safety and quality best practices by focusing
on the challenges experienced by patients and nurses in healthcare settings. The report helps
readers to understand that patient safety and quality of care is affected by communication. In this
paper, the authors link communication with adverse events, including medical errors, prolonged
hospital length of stay, and even readmission or the same health complications. Therefore, by
exploring the challenges that Francophones face when accessing and using healthcare services,
the researchers assert that the major cause is the language barrier. More specifically, untrained
and ad-hoc interpreters pose a risk to both the patient and the nurse since it creates the illusion of
adequate communication. Therefore, the article helps nursing students to understand both the
challenges of the language barrier and the role of trained interpreter services if there is no

RESOURCE TOOLKIT

3

preferred official language when providing care for culturally and linguistically diverse
populations.
Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou,
E. (2017, December). Importance of leadership style towards the quality of care measures in
healthcare settings: a systematic review. In Healthcare (Vol. 5, No. 4, p. 73). Multidisciplinary
Digital Publishing Institute.
This source is a systematic review conducted to assess whether or not a relationship
between various leadership styles and a healthcare system's quality exists. According to the
paper, management and leadership of healthcare processional are crucial such that it strengthens
the quality and integration of care. Thus, leadership involves establishing a relationship between
the leaders and the followers by directing and coordinating all team members to focus on a
common objective. The authors identified and analyzed different leadership styles, such as
transformational leadership, where the leaders encourage and motivate employees, which
involves more supervision. Others include absolute, or rather dictatorial, task-oriented, and
relationship-oriented leadership styles. The authors call upon health organizations to address the
healthcare sector's leadership gap in the dynamic and evolving environment. In their findings, the
authors conclude that leadership style is a key component for healthcare services quality.
Therefore, effective leadership styles are associated with increased patient satisfaction and
reduction of medical challenges. This article helps nursing students understand effective
leadership as one of the most critical components contributing to effective and successful
organizational outcomes. Also, the impact differs across different leadership styles.
Sharplin, G., Adelson, P., Kennedy, K., Williams, N., Hewlett, R., Wood, J., ... & Eckert, M.
(2019, December). Establishing and Sustaining a Culture of Evidence-Based Practice: An

RESOURCE TOOLKIT

4

Evaluation of Barriers and Facilitators to Implementing the Best Practice Spotlight Organization
Program in the Australian Healthcare Context. In Healthcare (Vol. 7, No. 4, p. 142).
Multidisciplinary Digital Publishing Institute.
In this article, the researchers conducted a study to determine and describe core factors
influencing the BPSO program's implementation. The scientists identified factors at the programlevel which act as facilitators or inhibit...


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