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I am in my bachelor program and i what support in my homework. its two diffrent assignment asessment 1 and assement 2, both have a documts with instructions. I only have an example for asessment 2 and is attchached with a template to use as a guide if you need to.
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Assessment 01 – Enhancing Quality and Safety
For this assessment, you will develop a 3–5-page paper that examines a safety quality issue in
a health care setting. You will analyze the issue and examine potential evidence-based and
best-practice solutions from the literature as well as the role of nurses and other stakeholders in
addressing the issue.
Before you complete the instructions detailed in the courseroom, first select one of the safety
quality issues below to analyze for this assessment. After you have selected one of the issues
from the list below, return to the detailed instructions in the courseroom to complete your
assessment.
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Diagnostic Errors: Diagnostic errors refer to situations where a diagnosis was missed,
wrong, or delayed as detected by some subsequent definitive test or finding. These
errors can have significant implications for patients, as they might receive unnecessary
treatments, face delays in appropriate care, or miss out on effective interventions
altogether.
o Patient Safety and Outcomes: A misdiagnosis or delayed diagnosis can lead to
inappropriate treatments, which might harm the patient or allow the actual
condition to worsen. For instance, a missed diagnosis of a heart attack could
lead to fatal consequences.
o Trust in Healthcare: Patients rely on healthcare professionals to accurately
identify and address their health concerns. Diagnostic errors can erode this trust,
making patients hesitant to seek care or follow medical advice in the future.
o Economic Implications: Diagnostic errors can lead to unnecessary treatments,
tests, and hospital stays, resulting in increased costs for both patients and
healthcare systems.
o Professional Implications: For healthcare professionals, being part of a
diagnostic error can have significant repercussions, including potential legal
actions, damage to professional reputation, and personal feelings of guilt or
inadequacy.
o Systemic Issues: Frequent diagnostic errors can indicate deeper systemic
problems within a healthcare institution, such as inadequate training, poor
communication, or insufficient resources.
o Emotional Toll on Patients: Being misdiagnosed can be emotionally distressing
for patients. They might undergo treatments or procedures they didn’t need, face
uncertainty about their health, or grapple with the implications of a late diagnosis.
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Healthcare-Associated Infections (HAIs): Healthcare-Associated Infections,
commonly referred to as HAIs, are infections that patients acquire while receiving
treatment for other conditions within a healthcare setting. These infections can occur in
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any healthcare setting, from hospitals to outpatient clinics. Understanding the
significance of HAIs is crucial for nursing students for the following reasons:
o Patient Morbidity and Mortality: HAIs can lead to severe health complications.
Depending on the type of infection and the patient’s underlying health conditions,
HAIs can result in prolonged illness, the need for intensive treatments, or even
death. For instance, sepsis, which can arise from an HAI, is a life-threatening
condition that requires immediate intervention.
o Extended Hospital Stays: Patients with HAIs often require extended hospital
stays for additional treatments, such as antibiotics or surgeries. This not only
increases the patient’s risk of acquiring other complications but also adds to their
emotional and psychological stress.
o Increased Healthcare Costs: The extended hospital stays, additional
treatments, and interventions associated with HAIs result in significant financial
burdens. These costs are borne by healthcare systems, insurance providers, and
often, the patients themselves.
o Antibiotic Resistance: The overuse or misuse of antibiotics to treat HAIs can
lead to the development of antibiotic-resistant strains of bacteria. These
“superbugs” are harder to treat and can spread to other patients, posing a
significant public health threat.
o Emotional and Psychological Impact: Acquiring an infection while seeking
treatment for another condition can be distressing for patients. They may feel
betrayed by the very system they trusted to heal them. This can lead to feelings
of anxiety, fear, and mistrust towards healthcare providers.
o Reputation and Trust: Just as with falls, repeated incidents of HAIs can impact
the reputation of a healthcare facility. High rates of HAIs can lead to decreased
public trust and potential legal implications.
o Regulatory Implications: Healthcare facilities are held to strict standards by
regulatory and accrediting bodies. High rates of HAIs can result in penalties,
increased inspections, and challenges in maintaining accreditation.
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For this assessment, you will analyze a safety quality issue in a health care setting and
identify a quality improvement (QI) initiative.- pick from the attached document
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 that you know what is
needed for a distinguished score.
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Explain factors leading to a specific patient-safety risk in a health care setting.
Explain evidence-based and best-practice solutions to improve patient safety
and reduce costs.
Explain how nurses can help coordinate care to increase patient safety and
reduce costs.
Identify stakeholders with whom nurses would coordinate to drive safety
enhancements with a specific safety quality issue.
Communicate using writing that is clear, logical, and professional, with correct
grammar and spelling, using current APA style.
Length of submission: 3–5 pages, plus title and reference pages.
Number of references: Cite a minimum of 4 sources of scholarly or professional
evidence that support your findings and considerations. Resources should be no
more than 5 years old.
APA formatting: References and citations are formatted according to current APA
style.
For this assessment, you can use a supplied template to conduct a root-cause
analysis-attached below . The completed assessment will be a scholarly paper
focusing on a quality or safety issue in a health care setting of your choice as well
as a safety improvement plan.
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.
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Analyze the root cause of a specific patient safety issue in an organization.
Apply evidence-based and best-practice strategies to address the safety issue.
Create a feasible, evidence-based safety improvement plan to address a
specific patient safety issue.
Identify organizational resources that could be leveraged to improve your
plan.
Communicate in writing that is clear, logical, and professional, with correct
grammar and spelling, using current APA style.
Example Assessment:-attached as well You may use the following to give you an idea
of what a Proficient or higher rating on the scoring guide would look like but keep in
mind that your Assessment 2 will focus on safe medication administration.
• Length of submission: Use the provided Root-Cause Analysis and
Improvement Plan template to create a 4–6 page root cause analysis and
safety improvement plan pertaining to a specific patient safety issue.
• Number of references: Cite a minimum of 3 sources of scholarly or
professional evidence that support your findings and considerations.
Resources should be no more than 5 years old.
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Root-Cause Analysis and Improvement Plan
Your Name
School of Nursing and Health Sciences, Capella University
NURS-FPX4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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Root-Cause Analysis and Improvement Plan
According to Spath (2011), root-cause analysis is a methodical approach that aims to
discover the causes of adverse events and near misses for the purpose of identifying
preventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls in
geropsychiatric patients was conducted at an inpatient mental health unit. The paper describes
and analyzes falls and discusses evidence-based strategies to reduce falls and determine a
safety improvement plan based on the utilization of existing organizational resources to
address these falls.
Root-Cause Analysis of Falls in Geropsychiatric Inpatients
According to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control and
Prevention reported that falls were a leading cause of unintentional injury death in adults
aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead to
serious head trauma are common among older adults. Injury falls are serious and could lead
to fractures, head injury, and intracranial bleed. According to the National Quality Forum
(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope et
al., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate their
health conditions (Powell-Cope et al., 2014).
Considering the adverse implications of falls in such patients, a root-cause analysis
was conducted on the 20 cases of falls reported over a period of one year at a geropsychiatric
inpatient facility. The aim of the analysis was to understand the causes of falls in
geropsychiatric patients at the unit. The analysis was conducted by a team of five experts
including clinicians, supervisors, and quality improvement personnel. The cases reported had
been registered by a team of nurses who collated the data related to the falls. All the falls
were described as cases of slipping or tripping, and patients mostly sustained injuries
involving pain, mild swelling, and abrasions, with only two of the cases involving minor
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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fractures. It was also observed that all the falls occurred near the beds of patients and during
the evening or night shifts when nursing teams were more likely to be understaffed.
Geropsychiatric patients are known to be susceptible to falls under the influence of
drugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in blood
pressure within three minutes of standing), ataxia (lack of voluntary muscular control caused
by injury to the central nervous system), and extrapyramidal slowing (impaired motor
functions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,
hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to these
kinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of falls
and noted that in over 50% of the cases, patients had been ambulating under the influence of
drugs. It was also noted that 80% of the patients who fell while ambulating under the
influence of drugs had been prescribed zolpidem.
At least 40% of the falls could be attributed to generalized weakness, disorientation,
and difficulty with mobility. Fall and injury risks are often complicated by behavioral
circumstances such as anger, anxiety, hyperarousal, and the inability to call for help or to
remember to call for help. Physical conditions that occur with substance abuse (such as
malnourishment and dehydration) co-exist with psychiatric disability and cause further
complications (Powell-Cope et al., 2014).
Another factor that plays a role in patient safety is infrastructure in hospitals. This was
particularly noteworthy as all the falls studied had occurred when patients ambulated near
their beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskid
footwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,
2014).
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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Application of Evidence-Based Strategies to Reduce Falls
Considering that all the falls reported occurred near the patients’ beds, infrastructural
changes such as the installation of bed- and chair-exit alarms are recommended. Falls from
beds are common in patients with cognitive impairments. Installing electronic alarm systems
was found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,
Phillips, Hill, & Dodd, 2014).
Strategies such as team engagement and proactive planning to avoid falls can be
implemented in inpatient geropsychiatric wards. Forming a quality and patient safety team
can serve as an essential safety net and drive a proactive approach rather than a reactive one
toward reducing sentinel events. Such a team could include existing staff in the unit that are
selected based on their skills and experience. The primary focus of the team would be to
identify, evaluate, measure, and improve processes and activities related to patient safety
within the unit (Serino, 2015).
Better management of medication must be implemented to reduce falls that occur
under the influence of drugs. Administering melatonin instead of zolpidem reduces the level
of sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroom
at night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).
Improvement Plan
The improvement plan involves a two-pronged approach: improving staff
effectiveness and coordination and implementing environmental modifications. The first part
of the plan focuses on increasing the effectiveness of patient monitoring and staff
coordination through intentional rounding, one-to-one observation of patients, and increased
communication among staff. Intentional rounding is a system wherein the nursing staff
conduct structured routine checks on patients at regular intervals. The duration of intervals is
decided based on the needs of patients in the unit. Intentional rounding is known to be
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
5
particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation is
recommended for high-fall-risk patients. One-to-one observation of patients by moving them
close to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinel
events can be prevented by promoting interdisciplinary collaboration in health care. Good
communication and collaboration between physicians, therapists, kinesio therapists, and
occupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).
The second part of the improvement plan focuses on environmental modifications to
existing infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alert
staff when a patient attempts to leave the chair or bed has proven to be effective in reducing
falls. These alarms can be attached to the patient directly or to the chair or bed the patient
uses (Wong Shee et al., 2014). Other recommended environmental modifications include
using creative display signage beside patients’ beds. This could be magnets next to the name
of a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Such
displays alert staff and visitors of the risk involved with each patient. The use of nonslip
strips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitary
ware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patient
safety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained to
facilitate and monitor the use of environmental modifications such as electronic alarms to
ensure their successful implementation.
It is crucial to identify and leverage existing organizational resources when
implementing the improvement plan. The first part of the improvement plan involves
utilizing the skills and expertise of existing staff members rather than hiring new members to
assist in fall prevention. To improve monitoring of patients, the staff members are trained on
intentional rounding techniques and one-to-one observation. The environmental interventions
suggested in the second part of the plan involve the installation of additional components to
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existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existing
resources reduces the overall cost and effort involved in implementing the plan and ensures
minimal disruption to ongoing patient routines and staff-led fall-prevention practices within
the unit.
Conclusion
Falls are the leading cause of unintentional injury deaths in geropsychiatric patients
and are largely preventable. A root-cause analysis of falls in such patients was conducted at
an inpatient mental health unit. Infrastructural gaps and ambulation under the influence of
drugs were found to be primary factors that precipitated the falls reported in the unit. The
paper discusses evidence-based strategies such as medication management, installation of
electronic alarms, and formation of a quality and patient safety team that would help reduce
falls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.
The plan involved improving staff effectiveness and coordination and implementing
environmental modifications.
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.
(2016). How to perform a root cause analysis for workup and future prevention of
medical errors: A review. Patient Safety in Surgery, 10.
http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8
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.
http://dx.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
Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN
Journal, 102(6), 617–628. https://doiorg.library.capella.edu/10.1016/j.aorn.2015.10.006
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. http://dx.doi.org/10.1097/NCQ.0000000000000054
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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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
2
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:
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What happened?
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Who detected the problem/event?
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Who did the problem/event affect?
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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:
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What was supposed to occur?
o Were there any steps that were not taken or did not happen as intended?
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What environmental factors (controllable and uncontrollable) had an influence?
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What equipment or resource factors had an influence?
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What human errors or factors may have contributed?
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Which communication factors may have contributed?
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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.
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Describe what the literature states about the factors that lead to the safety issue.
o For example, interruptions during medication administration increase the risk of
medication errors by specifically stated data.
o 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:
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Actions, new processes or policies, and/or professional development that will be
undertaken to address one or more of the root causes.
o Support these recommendations with references from the literature or professional
best practices.
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A description of the goals or desired outcomes of these actions.
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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.
o A brief note on resources that may need to be obtained for the success of the plan.
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o Consider what existing resources may be leveraged to enhance the improvement
plan?
Conclusion
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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.
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