Course material

1. Discussion: Root Cause Analysis and Safety Plan
Discussion: Root Cause Analysis and Safety PlanORDER HERE FOR ORIGINAL, PLAGIARISM-
FREE PAPERS ON Discussion: Root Cause Analysis and Safety PlanFor 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.assessment_2_instructions_4020.docxcf_exemplar_nurs_fp4020_assessment_2.pdfroot
_cause_analysis_and.docxUnformatted Attachment PreviewAssessment 2 Instructions:
RootCause Analysis and Safety Improvement Plan 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 rootcause 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: Discussion: Root

2. Cause Analysis and Safety PlanIdentify 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. Discussion: Root Cause Analysis and Safety PlanYou 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. Discussion: Root Cause
Analysis and Safety PlanNumber 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. Running

3. head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN Root-Cause Analysis and
Improvement Plan Learner’s Name Capella University Improving Quality of Care and
Patient Safety Root-Cause Analysis and Improvement Plan March, 2019 Copyright ©2019
Capella University. Copy and distribution of this document are prohibited. 1 ROOT-CAUSE
ANALYSIS AND IMPROVEMENT PLAN 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. ROOT-CAUSE ANALYSIS
AND IMPROVEMENT PLAN 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

4. 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. ROOT-CAUSE ANALYSIS
AND IMPROVEMENT PLAN 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.Discussion:
Root Cause Analysis and Safety PlanFalls 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. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 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

5. 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. ROOT-CAUSE ANALYSIS
AND IMPROVEMENT PLAN 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. ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 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). Discussion: Root Cause Analysis and Safety PlanQuality and patient safety teams in
the perioperative setting. AORN Journal, 102(6), 617–628.

6. 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. Running head: ROOT-CAUSE
ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis and Safety
Improvement Plan YOUR NAME NURS-FPX4020 Capella University Month, Year 1 ROOT-
CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN Root-Cause Analysis 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? 2 ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT PLAN 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 du …