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:
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Competency 1: Analyze the elements of a successful quality improvement initiative.
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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:
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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:
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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:
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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.
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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
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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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