Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan 

*This is Part one, Part two for this is posted separately as assignment 3 (Improvement Plan In-Service Presentation)*

     

 
   For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue.
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 Template [DOCX] 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]. 
• 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.
• 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.
    
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      Scoring Guide
  Use the scoring guide to understand how your assessment will be evaluated.

 

The purpose of this assignment is to examine essential leadership competencies to effectively lead individuals in an organization.

Complete the “Essential Leadership Competencies” worksheet attached.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, ADD REFERENCES

 

1. Complete the portfolio.

Elements of Portfolio

The student is responsible for the development of a CGE portfolio that includes the following elements in the following order (items in black font were part of the initial portfolio in NR631; items in blue font are to be added from work done in NR632) :

1. Project PICOt question
2. Abstract summary of project topic (approx. 500 words)
3. Literature review (may be copied and pasted from the NR631 week 3 assignment with revisions as necessary) Updated if appropriate
4. Reflection on Course Outcome Achievement
   1. List each course outcome as a heading in proper APA format
   2. For each course outcome provide a reflective summary of how you feel you have progressed in meeting this outcome through the resources and activities of both NR631 and NR632
      1. In NR631 you reflected on your progress halfway through your CGE experience.
      2. Review each course outcome and update your reflection based on the entire sixteen week CGE experience
5. Scholarly application sections of the following (in order) project management tools (may be copied and pasted from those assignments with revisions as necessary):
   1. Project Charter (NR631 Week 2)
   2. Project Scope (NR631 Week 2)
   3. Communication Plan (NR631 Week 4)
   4. Deliverables and CSF (NR631 Week 5)
   5. Work Breakdown Structure (NR631Week 6)
   6. Gantt Chart (NR631 Week 6)
   7. RACI (NR631 Week 7)
   8. Risk Register (NR631 Week 7)
   9. Monitor and Control documents (NR632 WK 2)
   10. Completion Document (NR632 WK6)
   11. Lessons Learned (NR632 WK6)
6. The following documents included as separate appendices in the following order:
   1. Learning Agreement
      1. From NR631 (Keep NR631 Learning Agreement)
         1. Signed (verified) by both student and mentor
         2. Reflective summary of progress through the end of CGE I of progress toward that goal
      2. From NR632 (add this as a separate document following the NR631 learning agreement)
         1. Signed (verified by both student and mentor
         2. Reflective summary of progress toward each goal at the end of the Concluding Graduate Experience
   2. Signed NR631 CGE activity log with a minimum of 72 hours
   3. Signed NR632 CGE activity log that demonstrates 144 total CGE hours
   4. Project Charter (NR631 Week 2)
   5. Project Scope (NR631 Week 2)
   6. Communication Plan (NR631 Week 4)
   7. Deliverables and CSF (NR631 Week 5)
   8. Work Breakdown Structure (NR631 Week 6)
   9. Gantt Chart (NR631 Week 6)
   10. RACI (NR631 Week 7)
   11. Risk Register (NR631 Week 7)
   12. Monitor and Control documents (NR632 WK 2)
   13. Completion Document (NR632 WK6)
   14. Lessons Learned (NR632 WK6

Preparing the Paper

1. All aspects of the portfolio must be completed.
2. Ideas and information from professional sources must be cited correctly using the current edition of the APA manual.
3. Grammar, spelling, punctuation, references, and citations are consistent with formal academic writing.

This is a Collaborative Learning Community (CLC) assignment.

Nursing theories are tested and systematic ways to implement nursing practice. Select a nursing theory and its conceptual model. Prepare a 10‐15 slide PowerPoint in which you describe the nursing theory and its conceptual model and demonstrate its application in nursing practice. Include the following:

Provide three evidence-based examples that demonstrate how the nursing theory supports nursing practice. Provide support and rationale for each.

Please look at the bottom for the Chapter related to the question. ( The Theory that my team choose was Example of Dorothy Orem’s Self-Care Deficit Theory )

Nursing Theory

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A theory is a collection of statements that explain a relationship between two or more ideas. Theory maintains a central role in the evolution of the nursing discipline. It is something all nurses use in their daily practices, whether known or not. Relatively new, nursing theory is a structure of purposeful and systematic ideas that help to organize disciplinary thinking and influence practice. Much discussion and debate have occurred regarding the various theory definitions. Levine (1995) promoted acceptance of nursing theory, which she called the intellectual life of nursing. She identified that students often fail to embrace nursing theory and do not fully grasp the importance of nursing theory and its relevance for practice and education.

Understanding nursing theory strengthens the focus of care by guiding nursing practice. It may help to think about nursing theories as various lenses used to view different perspectives of known nursing phenomena. For example, Dorothy Orem’s self-care deficit theory focuses on assisting others in managing self-care to maintain or improve human function at an effective level (Orem, 1995). Also, Sister Callista Roy’s adaptation theory explains how individuals are in constant interaction with a changing environment and that the individual must adapt to change to have a positive response (Creasia & Friberg, 2011).

Example of Dorothy Orem’s Self-Care Deficit TheoryAn elderly man recently received a total hip replacement. During the discharge process, the registered professional nurse educates the patient about many things, including activity restrictions, medications, and wound care. The nurse also reviews activities of daily living, such as showering and toileting. The nurse realizes that the patient’s balance may be altered and discusses fall precautions with the patient. Detailed discharge instructions are an example of moving the patient from a state of dependence on others for care to a state of independence and self-care.

Nursing theory is present in day-to-day interactions with patients. The core values derived from theoretical assumptions can serve as a foundation upon which to build practices. The goal of applying theory is to improve practice.

The nursing profession is an art and science involving a complex mix of many parts. Nurses are expected to perform the science of nursing through medical and technical competencies, such as nursing skills, academic knowledge, and professional performance. Nurses must become lifelong learners and engage in continuing education throughout their careers to maintain those nursing skills and competencies. Included in the science of nursing are theories, conceptual models, and research that is specific to nursing. The art of nursing requires a foundation of nursing skills, academic knowledge, and professional performance. It is difficult to define or measure the art of nursing other than by looking at the pronounced noticeability of its absence. Treating patients with dignity and respect, being cognizant of nonverbal cues, and using active listening and communication skills are all qualities patients and families value highly. Nurses should strive to find a balance between the science and the art of nursing in their practices (Palos, 2014).

Nursing is a knowledge-based discipline and profession that incorporates a body of knowledge to guide its practice (Smith & Parker, 2015). Because nursing is a profession, nurses are required to meet specific educational qualifications. Education is systematically obtained from colleges and universities that ultimately produce knowledge-based professional nurses who can practice autonomously. The following characteristics define the meaning of a professional (Creasia & Friberg, 2011):

• Formal education required
• Lifelong mission, recognized as life work
• Encompass knowledge
• Service to society
• Practice autonomously
• Practice guided by ethics
• Professional culture and values
• Compensation received

Metaparadigm

Theories are built upon a foundation of concepts. Theoretical statements compose a theory. The concepts incorporated into theoretical statements include areas of interest to the discipline. For nursing theory, these concepts include person, environment, health, and nursing, also referred to as metaparadigm. The metaparadigm includes basic assumptions regarding the theory and highlights areas vital to the nursing discipline and ultimately patient care (see Figure 2.3).

Figure 2.3

Metaparadigm of Nursing Concepts

Note. Adapted from “Nursing Metaparadigm Concepts,” by CJT Consulting & Education, 2017.

Person refers to the patient, client, individual, family, community, or group. These are the recipient(s) of said nursing care. Environment includes external and internal space associated with the person. Health encompasses all areas of, or lack of, the person(s) wellbeing. As the final metaparadigm component, nursing expresses the goal of nursing that is specific to the theory (McEwen, 2007).