Cause 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 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.

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.
  • Create a feasible, evidence-based safety improvement plan.
• Competency 2: Analyze factors that lead to patient safety risks.
  • Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
• Competency 3: Identify organizational interventions to promote patient safety.
  • Identify existing organizational resources that could be leveraged to improve a plan.
• 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.

Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help you to stay organized and concise.

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 in an organization.
• Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
• Identify organizational resources that could be leveraged to improve your plan.
• Create a feasible, evidence-based safety improvement plan.
• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

ADDITIONAL REQUIREMENTS

• Length of submission: Use the provided template to create a 4–6 page root cause analysis and safety improvement plan. A title page is not required but you must include a reference list as per the template.
• 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.

IMPORTANT NOTE REGARDING WORD LIMIT REQUIREMENTS:

Please note that each and every assignment has its own word limit.

 

It is realistic to think that poor communities have existing and unrecognized assets that could lead to economic opportunities. Poor communities are loaded with a plethora of gifts would lead to increase financial revenue if marketed and shared within the community. In order to promote and share gifts within the community, there would have to be a unity in the community by establishing the culture within the community (McKnight).

Benefits when it comes to the effectiveness of ABCD in mobilizing communities for development could affect education and clothing. Scholarly residents within the community could offer tutoring to students that are struggling in school. Improved education leads to better jobs and aids in steering students toward higher education and a career in a field that pays a healthy salary.

community closet

Clothing as a benefit because of the lack of appropriate clothing for members with the community. If there was a community closet established that would allow residents to either exchange clothes are sell for minimal amounts in efforts to offer those less fortunate the opportunity to wear appropriate clothing. Dressing the part aids in building self-esteem. The gifts that community partners offer aids in communities working together and creating new connections and relationships.

Two challenges would when it comes to the effectiveness of ABCD in mobilizing communities for development would the lack of funding and appropriate space. Financial aid is important in establishing an adequate tutoring system. The time it takes to work as a tutor is time a person could work outside of the community. Appropriate space is a challenge for tutoring along with an appropriate place for the donation, exchange and selling of clothing items.

References

McKnight, J. (n.d.). A Basic Guide to ABCD Community Organizing. DePaul University.

 

context of ethics

Respond to the bold paragraph ABOVE by using one of the option below… in APA format with At least two references and a minimum of 200 words….. .(The List of References should not be older than 2016 and should not be included in the word count.) Include at least one scholarly reference and appropriate in-text citations and Address all points on the DQ. One point will be deducted for not addressing each item mentioned above. Remember that presenting someone else’s work as your own is plagiarism.

 

 

 

 

• Ask a probing question.
• Share an insight from having read your colleague’s posting.
• Offer and support an opinion.

 

 

 

• Validate an idea with your own experience.
• Make a suggestion.
• Expand on your colleague’s posting.

 

 

 

 

 

 

Be sure to support your postings and responses with specific references to the Learning Resources.

It is important that you cover all the topics identified in the assignment. Covering the topic does not mean mentioning the topic BUT presenting an explanation from the context of ethics and the readings for this class

 

To get maximum points you need to follow the requirements listed for this assignments 1) look at the word/page limits 2) review and follow APA rules 3) create subheadings to identify the key sections you are presenting and 4) Free from typographical and sentence construction errors.

REMEMBER IN APA FORMAT JOURNAL TITLES AND VOLUME NUMBERS ARE ITALICIZED.

H

 

 

 

 

References

American Psychological Association. Publication Manual of the American Psychological Association (7th Ed.). Washington, DC: Author.

Assignment: The Impact of Nursing Informatics on Patient Outcomes and Patient Care Efficiencies

In the Discussion for this module, you considered the interaction of nurse informaticists with other specialists to ensure successful care. How is that success determined?

Patient outcomes and the fulfillment of care goals is one of the major ways that healthcare success is measured. Measuring patient outcomes results in the generation of data that can be used to improve results. Nursing informatics can have a significant part in this process and can help to improve outcomes by improving processes, identifying at-risk patients, and enhancing efficiency.

To Prepare:

• Review the concepts of technology application as presented in the Resources.
• Reflect on how emerging technologies such as artificial intelligence may help fortify nursing informatics as a specialty by leading to increased impact on patient outcomes or patient care efficiencies.

The Assignment: (4-5 pages not including the title and reference page)

In a 4- to 5-page project proposal written to the leadership of your healthcare organization, propose a nursing informatics project for your organization that you advocate to improve patient outcomes or patient-care efficiency. Your project proposal should include the following:

patient care efficiencies

• Describe the project you propose.
• Identify the stakeholders impacted by this project.
• Explain the patient outcome(s) or patient-care efficiencies this project is aimed at improving and explain how this improvement would occur. Be specific and provide examples.
• Identify the technologies required to implement this project and explain why.
• Identify the project team (by roles) and explain how you would incorporate the nurse informaticist in the project team.

Learning Ressources

 

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)

Mosier, S., Roberts, W. D., & Englebright, J. (2019). A Systems-Level Method for Developing Nursing Informatics Solutions: The Role of Executive Leadership. JONA: The Journal of Nursing Administration, 49(11), 543-548.

Ng, Y. C., Alexander, S., & Frith, K. H. (2018). Integration of Mobile Health Applications in Health Information Technology Initiatives: Expanding Opportunities for Nurse Participation in Population Health. CIN: Computers, Informatics, Nursing, 36(5), 209-213.

Sipes, C. (2016). Project management: Essential skill of nurse informaticists. Studies in Health Technology and Informatics, 225, 252-256.

Nursing 235: Adult Health II

Laboratory Analysis Case Scenario

Patient Initials: KH Age: 60

Height: 65 in

Weight: 67.13 kg

HPI

KH presented to the ED with c/o bug bite on L thigh that occurred about 10 days ago that has turned into an abscess “as big as a personal sized watermelon.” Patient also reported urinary burning, frequency, and urgency. The ED, WBC 37,000, glucose 317, bicarbonate 13, anion gap 25, large amount of acetone, HgbA1C 10.3. Patient was admitted to the hospital for evaluation and management of DKA, DVT, abscess, and UTI.

Past Medical/Surgical History:

· Type 2 Diabetes Mellitus

· Previous tobacco use (1/2 pack per day)

· MVA 7/13/20: pain in pelvis and knees since accident

Significant Clinical Events:

8/23/20

· Wound culture: staph aureus, methicillin sensitive

· Blood culture: no growth after 5 days (determined on 8/28/10)

· Urine analysis indicates infection and DKA

· Insulin drip for DKA

· IV antibiotics for UTI, multiple abscesses

· IV antifungals for multiple abscesses & topical antifungal for yeast infection

8/24/20

diffuse myositis & muscle necrosis

· Deep muscle abscess extends to femur (visualized via CT)

· I&D done in OR discovered diffuse myositis & muscle necrosis

· S/p insulin drip for DKA treatment

· Wound nurse consult

· Infectious disease consult

8/26/20

· I&D done in OR on L thigh, R groin abscess

· Patient experience bleeding post-op

· SCD and TED hose prescribed for DVT

8/28/20

· d/c Coumadin due to post procedure bleeding, switched to Lovenox

8/29/20

· bleeding from wound, changed lovenox to heparin

· anemia due to blood loss s/p I&D, received 2 units packed RBC

· Constipation for 1 wk, senna, colace, lactulose

8/30/20

· blood glucose 340-360 mg/dL all day

· patient complains of recent onset visual disturbances (since hospitalization on 8/23/10)

· notify MD, increase levemir to 32 units daily

· MD d/c IV antibiotic and heparin, change to PO antibiotics and coumadin

antibiotic and heparin

Test/Result	Admit 8/23/20	Sun 8/29/20	Mon 8/30/20
Hemoglobin (g/dL)	13.8	7.4L	9.1L
Hematocrit (%)	42.2	21.1L	25.8L
RBC (M/uL)	4.35	2.28L	2.82L
WBC (K/Ul)	37.2H	11.4H	14.2H
MCV (FL)	97.1H	92.5	91.7
MCH (PG)	31.7	32.3	32.3
MCHC (g/dL)	32.7	35	35.2
RDW (%)	15.1H	15.8H	15.5H
PLT (K/uL)	461H	408	428H
MPV (FL)	7.5	6.6	6.3
PT (Sec.)	n/a	9.7	10.0
INR	n/a	0.93	0.96
PTT (Sec.)	n/a	29.4 @ 0600 30.3 @ 1400	24.6 @ 0600 48.1 @ 1400
guaiac			negative
BUN (mg/dL)	15	7L	6L
Creatinine–mg/dl	0.96	0.29L	0.36L
GFR AF	54	n/a	>60
BNP	277H
AGAP	25.0H	8.0	9.0
Chlroide (mmol/L)	92L	102	98
CO2 (mmol/L)	13L	24	25
Potassium (mmol/L)	4.8	4.1	4.0
Sodium (mmol/L)	130L	134L	132L
Glucose (U/L)	397H	266H	368H
HgbA1C	10.3H
Urinalysis Color Yellow	yellow
Appearance Clear	Hazy
Spec. Gravity 1.002-1.030	1.025
PH 4.5-8.0	5.5
Protein Negative	200mg/dL
GLU Normal	1000mg/dL
Ketones Negative	>150
Blood Negative	300
Urobilinogen Normal	2mg/dL
Leuk Ester Negative	500

Dx. Tests Date and Client Results

Gram Stain	8/23/10 & 8/25/10 wound culture: gram positive cocci staph like
Cultures/ Sensitivities	blood culture 8/23/10: no growth after 5 days (8/28/10) wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins 8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT 8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities)
Therapeutic Drug Levels	PT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin.

Dx. Tests Date and Client Results

CXR	8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF.
CT/US/ Nuc Med/ Spec Proc	8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged. 8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cm
Cardiac monitoring	Measure and compare with report: PR interval: QRS: QT interval: P-P interval regular: R-R interval regular:

Medications

Cefazolin (Ancef) 2g/D5W 110mL IVPB q 8hrs infuse over 30 min

Clindamycin (Cleocin) 900mg IVPB infuse over 30 min

Fluconazole (Diflucan) 100mg PO Q 24hrs

Heparin 100 units/mL standard infusion

Warfarin (Coumadin)

Nystatin Topical

Insulin Aspart 0-14 units SQ 4 times daily ac/hs

Insulin Detemir (Levemir) 32 units SQ daily

Polyethylene glycol (Golytely) 400mL PO one time

Acetaminophen (Tylenol) 650mg PO q 4 hrs prn

Oxycodone (Oxycontin) 5 mg PO Q 4 hrs prn

Morphine (Duramorph) 4mg IV Q 3hrs prn

Hydromorphone (Dilaudid) 1mg IV Q 3hrs prn

Calcium Carbonate (Tums) chewable 500mg PO 3x daily prn

Promethazine (Phenergan) 6.25mg IV q 4hrs prn

Sennosides/ docusate sodium 8.6mg/50mg 1 tablet PO BID prn

Trazadone (Desyrel) 25mg PO hs prn

Assignment: Developing Organizational Policies and Practices

Competing needs arise within any organization as employees seek to meet their targets and leaders seek to meet company goals. As a leader, successful management of these goals requires establishing priorities and allocating resources accordingly.

Within a healthcare setting, the needs of the workforce, resources, and patients are often in conflict. Mandatory overtime, implementation of staffing ratios, use of unlicensed assisting personnel, and employer reductions of education benefits are examples of practices that might lead to conflicting needs in practice.

competing needs within an organization

Leaders can contribute to both the problem and the solution through policies, action, and inaction. In this Assignment, you will further develop the white paper you began work on in Module 1 by addressing competing needs within your organization.

The Assignment (4-5 pages):

ethical shortcomings

Recommend one or more policy or practice changes designed to balance the competing needs of resources, workers, and patients, while addressing any ethical shortcomings of the existing policies. Be specific and provide examples.

· Cite evidence that informs the healthcare issue/stressor and/or the policies, and provide two scholarly resources in support of your policy or practice recommendations.

·

NOTE – Shortage of nurse is the pertinent healthcare issue in my organization

APA format

Resources

American Nurses Association (2015). Code of ethics for nurses . provision 6 p23-26

Kelly ,P ,Porr, C (2018)