Root-Cause Analysis and Safety Improvement Plan
Instructions
You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.
Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.
· Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
· Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
· Create a feasible, evidence-based safety improvement plan for safe medication administration.
· Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
· Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
· Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
· Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
· APA formatting: Format references and citations according to current APA style.
Demonstration of Proficiency
· Competency 1: Analyze the elements of a successful quality improvement initiative.
. Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration.
. Create a viable, evidence-based safety improvement plan for safe medication administration.
· Competency 2: Analyze factors that lead to patient safety risks.
. Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
· Competency 3: Identify organizational interventions to promote patient safety.
. Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
· Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
. Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
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Root-Cause Analysis and Safety Improvement Plan
Your Name
School of Nursing and Health Sciences, Capella University
NURS4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year
Root-Cause Analysis and Safety Improvement Plan
Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.
Analysis of the Root Cause
Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:
· What happened?
· Who detected the problem/event?
· Who did the problem/event affect?
· How did it affect them?
Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:
· What was supposed to occur?
· Were there any steps that were not taken or did not happen as intended?
· What environmental factors (controllable and uncontrollable) had an influence?
· What equipment or resource factors had an influence?
· What human errors or factors may have contributed?
· Which communication factors may have contributed?
These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event.
Application of Evidence-Based Strategies
Identity best practices strategies to address the safety issue or sentinel event.
· Describe what the literature states about the factors that lead to the safety issue.
· For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.
· Explain how the strategies could be addressed in safety issues or sentinel events.
Improvement Plan with Evidence-Based and Best-Practice Strategies
Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain:
· Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
· Support these recommendations with references from the literature or professional best practices.
· A description of the goals or desired outcomes of these actions.
· A rough timeline of development and implementation for the plan.
Existing Organizational Resources
Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.
· A brief note on resources that may need to be obtained for the success of the plan.
· Consider what existing resources may be leveraged to enhance the improvement plan?
Conclusion
References
Reference page should be double spaced throughout without extra spaces between entries.
Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.
