1. NURS 4020 Capella University Root Cause Analysis and Safety Plan
Discussion
NURS 4020 Capella University Root Cause Analysis and Safety Plan DiscussionORDER HERE
FOR ORIGINAL, PLAGIARISM-FREE PAPERS ON NURS 4020 Capella University Root Cause
Analysis and Safety Plan DiscussionFor 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

2. 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: NURS 4020
Capella University Root Cause Analysis and Safety Plan DiscussionIdentify 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. NURS 4020 Capella University
Root Cause Analysis and Safety Plan DiscussionYou 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. NURS
4020 Capella University Root Cause Analysis and Safety Plan DiscussionNumber of
references: Cite a minimum of 3 sources of scholarly or professional evidence that support

3. 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 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

4. 80% of the patients who fell while ambulating under the influence of drugs had been
prescribed zolpidem. At least 40% of the falls could be attributed to generalized weakness,
disorientation, and difficulty with mobility. Fall and injury risks are often complicated by
behavioral circumstances such as anger, anxiety, hyperarousal, and the inability to call for
help or to remember to call for help. Physical conditions that occur with substance abuse
(such as malnourishment and dehydration) co-exist with psychiatric disability and cause
further complications (Powell-Cope et al., 2014). Another factor that plays a role in patient
safety is infrastructure in hospitals. This was particularly noteworthy as all the falls studied
had occurred when patients ambulated near their beds. The use of beds with adjustable
height, bed- and chair-exit alarms, and nonskid footwear are known to prevent fall-related
injuries in psychiatric patients (Powell-Cope et al., 2014). Copyright ©2019 Capella
University. Copy and distribution of this document are prohibited. 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. NURS 4020
Capella University Root Cause Analysis and Safety Plan DiscussionFalls 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

5. 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. 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

6. 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. 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 …