Description
I have added a total of 4 assesments. Please let me know.
For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration 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.
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Introduction
Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).
The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate 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.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
Competency 2: Analyze factors that lead to patient safety risks.
Explain factors leading to a specific patient-safety risk focusing on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
REFERENCES
Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
Scenario
Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines.
Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.
For this assessment:
Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.
Instructions
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.
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.
Explain factors leading to a specific patient-safety risk focusing on medication administration.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
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.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
View Scoring Guide
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For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.
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Introduction
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.
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.
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.
Professional Context
Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.
Scenario
For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:
The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
Instructions
The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the 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] Download Root-Cause Analysis and Improvement Plan [DOCX]template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.
Analyze the root cause of a 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.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.
Assessment 2 Example [PDF] Download Assessment 2 Example [PDF].
Additional Requirements
Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to 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.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
View Scoring Guide
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For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.
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Introduction
As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.
The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).
As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.
You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.
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.
Explain the need and process to improve safety outcomes related to medication administration.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
REFERENCE
Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), s16–s17.
Professional Context
As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.
Scenario
For this assessment it is suggested you take one of two approaches:
Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or
Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.
Instructions
The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.
Be sure that your presentation 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.
List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Explain the need for and process to improve safety outcomes related to medication administration.
Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.
There are various ways to structure an in-service session; below is just one example:
Part 1: Agenda and Outcomes.
Explain to your audience what they are going to learn or do, and what they are expected to take away.
Part 2: Safety Improvement Plan.
Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
Explain why it is important for the organization to address the current situation.
Part 3: Audience’s Role and Importance.
Discuss how the staff audience will be expected to help implement and drive the improvement plan.
Explain why they are critical to the success of the improvement plan focusing on medication administration.
Describe how their work could benefit from embracing their role in the plan.
Part 4: New Process and Skills Practice.
Explain new processes or skills.
Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
Part 5: Soliciting Feedback.
Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
Explain how you might integrate this feedback for future improvements.
Remember to account for activity and discussion time.
For tips on developing PowerPoint presentations, refer to:
Capella University Library: PowerPoint Presentations.
Guidelines for Effective PowerPoint Presentations [PPTX].
Additional Requirements
Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be at least 10 slides and no more than 15 slides (not including the title, conclusion, or references slides).
Speaker notes: Speaker notes (located under each slide) should reflect what you would actually say if you were delivering the presentation to an audience. This presentation does NOT require audio or a transcript. Another presenter would be able to use the presentation by following the speaker’s notes.
APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
View Scoring Guide
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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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Introduction
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 reasons and relevant situations for resource tool kit to be used by its target audience.
Communicate resource tool kit in a clear, logically structured, and professional manner that applies 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 in-service 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:
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.
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. https://gsuite.google.com/learning-center/products…
Google. (n.d.). Sites. https://sites.google.com
Google. (n.d.). Sites help. 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.
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 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] Download 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 Improved Heparin Infusion Safety, 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
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
View Scoring Guide
Unformatted Attachment Preview
Enhancing Quality and Safety Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Explain factors
leading to a specific
patient-safety risk
focusing on
medication
administration.
Does not identify
factors leading to a
specific patientsafety risk focusing
on medication
administration.
Identifies factors
leading to a specific
patient-safety risk
focusing on medication
administration.
Explains factors
leading to a specific
patient-safety risk
focusing on
medication
administration.
Explains factors leading
to a specific patientsafety risk focusing on
medication
administration. Makes
reference to specific
data, evidence, or
standards to illustrate
the safety risk.
Explain evidencebased and bestpractice solutions to
improve patient
safety focusing on
medication
administration and
reducing costs.
Does not identify
evidence-based and
best-practice
solutions to improve
patient safety
focusing on
medication
administration and
reducing costs.
Identifies evidencebased and bestpractice solutions to
improve patient safety
focusing on medication
administration and/or
discusses reducing
costs but not both.
Explains evidencebased and bestpractice solutions to
improve patient
safety focusing on
medication
administration and
reducing costs.
Explains evidencebased and best practice
solutions to improve
patient safety focusing
on medication
administration and
reducing costs. Makes
explicit reference to
scholarly or professional
resources to support
explanation.
Explain how nurses
can help coordinate
care to increase
patient safety with
medication
administration and
reduce costs.
Does not identify
how nurses can help
coordinate care to
increase patient
safety with
medication
administration and
reduce costs.
Identifies how nurses
can help coordinate
care to increase
patient safety with
medication
administration and/or
how to reduce costs
but not both.
Explains how nurses
can help coordinate
care to increase
patient safety with
medication
administration and
reduce costs.
Explains how nurses
can help coordinate care
to increase patient
safety with medication
administration and
reduce costs, providing
specific examples
related to a patient
safety risk.
Identify
stakeholders with
whom nurses would
need to coordinate
to drive quality and
safety
enhancements with
medication
administration.
Does not identify
stakeholders with
whom nurses would
need to coordinate
to drive quality and
safety
enhancements with
medication
administration.
Identifies stakeholders,
but their relevance to
collaboration with
nurses or their ability
to drive quality and
safety enhancements
with medication
administration is
unclear.
Identifies
stakeholders with
whom nurses would
need to coordinate
to drive quality and
safety
enhancements with
medication
administration.
Identifies stakeholders
with whom nurses would
need to coordinate to
drive quality and safety
enhancements with
medication
administration, noting
the relevance and
potential importance of
the stakeholders.
Organize content so
ideas flow logically
with smooth
transitions; contains
few errors in
grammar or
punctuation, word
choice, and spelling.
Does not organize
content for ideas.
Lacks logical flow
and smooth
transitions.
Organizes content with
some logical flow and
smooth transitions.
Contains errors in
grammar or
punctuation, word
choice, and spelling.
Organizes content
so ideas flow
logically with smooth
transitions; contains
few errors in
grammar or
punctuation, word
choice, and spelling.
Organizes content with
a clear purpose. Content
flows logically with
smooth transitions using
coherent paragraphs,
correct grammar or
punctuation, word
choice, and free of
spelling errors.
Apply APA
formatting to in-text
citations and
references
exhibiting nearly
Does not apply APA
formatting to
headings, in-text
citations, and
references. Does not
Applies APA formatting
to in-text citations,
headings and
references incorrectly
or inconsistently,
detracting noticeably
Applies APA
formatting to in-text
citations and
references
exhibiting nearly
Exhibits strict and
flawless adherence to
APA formatting of
headings, in-text
citations, and
CRITERIA
NON-PERFORMANCE
BASIC
flawless adherence
to APA format.
use quotes or
from the content.
paraphrase correctly. Inconsistently uses
headings, quotes or
paraphrasing.
PROFICIENT
DISTINGUISHED
flawless adherence
to APA format.
references. Quotes and
paraphrases correctly.
1
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.
2
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.
3
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).
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4
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
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
6
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.
7
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.
1
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:
•
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?
o 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?
3
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.
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:
•
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.
•
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.
o A brief note on resources that may need to be obtained for the success of the plan.
4
o Consider what existing resources may be leveraged to enhance the improvement
plan?
Conclusion
5
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.
Root-Cause Analysis and Safety Improvement Plan Scoring Guide
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Analyze the root
cause of a patient
safety issue or a
specific sentinel
event pertaining to
medication
administration in an
organization.
Does not identify the
root cause of a
patient safety issue
or a specific sentinel
event pertaining to
medication
administration in an
organization.
Identifies the root
cause of a patient
safety issue or a
specific sentinel event
pertaining to
medication
administration in an
organization.
Analyzes the root
cause of a patient
safety issue or a
specific sentinel
event pertaining to
medication
administration in an
organization.
Analyzes the root cause
of a patient safety issue or
a specific sentinel event
pertaining to medication
administration in an
organization, noting the
degree to which various
elements contributed to
the safety issue or
sentinel event pertaining
to medication
administration.
Apply evidencebased and bestpractice strategies
to address the
safety issue or
sentinel event
pertaining to
medication
administration.
Does not describe
evidence-based and
best-practice
strategies pertaining
to medication
administration.
Describes evidencebased and bestpractice strategies but
their relevance to the
safety issue or
sentinel event
pertaining to
medication
administration is
unclear.
Applies evidencebased and bestpractice strategies
to address the
safety issue or
sentinel event
pertaining to
medication
administration.
Applies evidence-based
and best-practice
strategies to address the
safety issue or sentinel
event pertaining to
medication administration,
detailing how the
strategies will address the
safety issue or sentinel
event pertaining to
medication administration.
Create a viable,
evidence-based
safety improvement
plan for safe
medication
administration.
Does not create a
viable, evidencebased safety
improvement plan
for safe medication
administration.
Creates a safety
improvement plan for
safe medication
administration that
lacks appropriate,
convincing evidence
of its viability.
Creates a viable,
evidence-based
safety improvement
plan for safe
medication
administration.
Creates a viable,
evidence-based safety
improvement plan for safe
medication administration
that makes explicit
reference to scholarly or
professional resources to
support the plan.
Identify existing
organizational
resources that could
be leveraged to
improve a safety
improvement plan
for safe medication
administration.
Does not identify
existing
organizational
resources that could
be leveraged to
improve a safety
improvement plan
for safe medication
administration.
Identifies existing
organizational
resources, but their
relevance and
usefulness to quality
and safety
improvement for safe
medication
administration are
unclear.
Identifies existing
organizational
resources that could
be leveraged to
improve a safety
improvement plan
for safe medication
administration.
Identifies existing
organizational resources
that could be leveraged to
improve a safety
improvement plan for safe
medication administration,
prioritizing them according
to potential impact.
Organize content so
ideas flow logically
with smooth
transitions; contains
few errors in
grammar or
punctuation, word
choice, and spelling.
Does not organize
content for ideas.
Lacks logical flow
and smooth
transitions.
Organizes content
with some logical flow
and smooth
transitions. Contain
errors in grammar or
punctuation, word
choice, and spelling.
Organizes content
so ideas flow
logically with
smooth transitions;
contains few errors
in grammar or
punctuation, word
choice, and spelling.
Organizes content with a
clear purpose. Content
flows logically with
smooth transitions using
coherent paragraphs,
correct grammar or
punctuation, word choice,
and free of spelling errors.
Apply APA
formatting to in-text
citations and
references
exhibiting nearly
Does not apply APA
formatting to
headings, in-text
citations, and
references. Does
Applies APA
formatting to in-text
citations, headings
and references
incorrectly or
Applies APA
formatting to in-text
citations and
references
exhibiting nearly
Exhibits strict and flawless
adherence to APA
formatting of headings, intext citations, and
CRITERIA
NON-PERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
flawless adherence
to APA format.
not use quotes or
paraphrase
correctly.
inconsistently,
detracting noticeably
from the content.
Inconsistently uses
headings, quotes or
paraphrasing.
flawless adherence
to APA format.
references. Quotes and
paraphrases correctly.
Guidelines for Effective
PowerPoint Presentations
Introduction
One concern about visual presentations is that the technology
used to create them can be used in such a way that it actually
detracts from the message rather than enhances it. To help
you consider carefully how your message is presented so that
it reflects care, quality, and professionalism, consider the
information provided in the remaining slides.
NOTE: This presentation serves as an example in itself, by
utilizing all of the guidelines mentioned.
Outline
The following topics will be covered:
▪ Writing
▪ Bullets
▪ Organization
▪ Tables
▪ Audience
▪ Font
▪ Design
▪ Speaker Notes
▪ Images
Writing
▪ Present ideas succinctly with lean prose.
▪ Use short sentences.
▪ Use active, rather than passive voice.
▪ Avoid negative statements, if possible.
▪ Avoid double negative entirely.
▪ Check spelling and grammar.
▪ Use consistent capitalization rules.
Organization
▪ Develop a clear, strategic introduction to provide context
for the presentation.
▪ Develop an agenda or outline slide to provide a roadmap
for the presentation.
▪ Group relevant pieces of information together.
▪ Integrate legends and keys with charts and tables.
▪ Organize slides in logical order.
▪ Present one concept or idea per slide.
▪ Use only one conclusion slide to recap main ideas.
Audience
▪ Present information at language level of intended audience.
▪ Do not use jargon or field-specific language.
▪ Follow the 70% rule—If it does not apply to 70% of your
audience, present it to individuals at a different time.
Design
▪ Use a consistent design throughout the presentation.
▪ Keep layout and other features consistent.
▪ Use the master slide design feature to ensure consistency.
▪ Use consistent horizontal and vertical alignment of slide
elements throughout the presentation.
▪ Leave ample space around images and text.
Images
▪ When applicable, enhance text-only slide content by
developing relevant images for your presentation.
▪ Do not use gratuitous graphics on each slide.
▪ Use animations only when needed to enhance meaning. If
selected, use them sparingly and consistently.
Bullets
▪ Use bullets unless showing rank or sequence of items.
▪ If possible, use no more than five bullet points and eight
lines of text total per slide.
Tables
▪ Use simple tables to show numbers, with no more than 4
rows x 4 columns.
▪ Reserve more detailed tables for a written summary.
Font
▪ Keep font size at 24 point or above for slide titles.
▪ Keep font size at 18 or above for headings and explanatory
text.
▪ Use sans serif fonts such as Arial or Verdana.
▪ Use ample contrast between backgrounds and text.
Speaker Notes
▪ Summarize key information.
▪ Provide explanation.
▪ Discuss application and implication to the field, discipline or
work setting.
▪ Document the narration you would use with each slide.
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