NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan

Root-Cause Analysis and Improvement Plan

Root cause analysis is a systematic method aimed at uncovering the underlying causes of adverse events and near misses (Martin-Delgado et al., 2020). Its (NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan) primary objective is to identify these causes to implement preventive measures effectively. Understanding the root causes behind diagnostic errors is essential for improving patient outcomes and enhancing the quality of healthcare delivery (Jussupow et al., 2021). The paper describes diagnostic errors, conducts analysis, and explores evidence-based strategies for their reduction. It also devises a safety improvement plan utilizing available organizational resources to address these errors effectively.
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NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Analyze the Root Cause of Diagnostic Errors – NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan

In March 2022, a 28-year-old male patient presented to the emergency department with abdominal pain and nausea one-week post-discharge from abdominal surgery, which included the placement of an abdominal drain. Despite being admitted and scheduled for a drain replacement the following day, the patient’s condition deteriorated rapidly upon arrival, exhibiting symptoms of tachycardia, hypotension, and hypoxia (Gleason, 2022). The nursing staff, familiar with the patient, observed a sudden increase in abdominal size, signaling a potential emergent issue.

In this specific scenario (Gleason, 2022), several critical factors contributed to the unfortunate outcome. Firstly, there was a failure to recognize the significance of the patient’s rapidly enlarging abdomen by the clinical team. The nurse’s attempt to communicate this observation was disregarded, leading to a delay in addressing the emergent issue. Furthermore, the team’s focus on investigating potential pulmonary embolism and sepsis led to overlooking the possibility of an abdominal aortic aneurysm, which was later determined to be the cause of the patient’s deterioration.

Environmental factors, such as the presence of spinal hardware complicating comprehensive imaging, likely influenced the diagnostic process. Additionally, the lack of interdisciplinary collaboration and communication within the clinical team hindered the timely identification of the underlying issue. The absence of a structured approach to patient assessment and decision-making also played a role in the missed diagnosis.

The root cause of this sentinel event (Gleason, 2022) can be attributed to a combination of factors, including failure to prioritize patient assessment (NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan), inadequate communication among team members, and a lack of consideration for alternative diagnoses. Additionally, the absence of a systematic approach to managing patients with complex medical histories and physical limitations contributed to the delayed diagnosis of the abdominal aortic aneurysm.

Application of Evidence-Based Strategies to Diagnostic Errors

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan indicates that diagnostic errors stem from multifactorial causes, including individual, organizational, and system-wide factors (Jawad Al-Khafaji, & Sarah Mossburg, 2023). Implementing a systematic approach to the diagnostic process can help mitigate these errors.  Healthcare organizations can develop standardized protocols and workflows for diagnostic procedures, ensuring clear communication channels among healthcare team members. This includes incorporating checklists and decision-support tools into clinical practice to guide clinicians through the diagnostic process and reduce cognitive biases. 

Poor communication among healthcare team members contributes to diagnostic errors, as seen in the case where the nurse’s observation of a rapidly enlarging abdomen was overlooked (Jawad Al-Khafaji, & Sarah Mossburg, 2023). Encourage interdisciplinary collaboration and empower frontline staff, such as nurses, to voice concerns and observations regarding patient care. Implementing structured communication tools, like SBAR (Situation, Background, Assessment, Recommendation) can improve information exchange and promote a shared understanding among team members.

Addressing human factors and cognitive biases through clinician training and fostering a culture of mindfulness and reflection can help mitigate the impact of biases on diagnostic reasoning. Leveraging technology, such as clinical decision support tools integrated into the workflow, and cultivating a patient-centered approach through effective communication skills and patient engagement further enhance diagnostic accuracy and promote patient safety.

 By implementing NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan best practices strategies, healthcare organizations can mitigate the factors contributing to diagnostic errors and enhance patient safety across clinical settings (Jawad Al-Khafaji, & Sarah Mossburg, 2023). These approaches require a comprehensive, systems-based approach that integrates technological advancements, organizational culture change, and ongoing education and training for healthcare providers.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The safety improvement plan devised to address diagnostic errors related to interruptions during medication administration involves implementing a standardized process supported by evidence from a study by Kavanagh. (2020), which demonstrated an 88.5% reduction in distractions and interruptions. This plan aims to enhance patient safety significantly & NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan. It includes establishing a designated, distraction-free room for medication administration, comprehensive training for nursing staff on adherence to medication administration protocols, and the implementation of a “do not disturb – med pass in process” signage protocol.

The overarching goal is to minimize interruptions during medication administration to improve nurse focus, reduce diagnostic errors, and elevate overall care quality. Implementation will begin with staff training sessions followed by the introduction of the designated medication administration room and signage Kavanagh. (2020). Through this systematic approach, the healthcare setting aims to create a safer environment for medication administration, ultimately mitigating the risk of diagnostic errors and improving patient outcomes.

Existing Organizational Resources – NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan

Existing organizational personnel and resources play a crucial role in facilitating the successful implementation of the safety improvement plan aimed at mitigating diagnostic errors during medication administration (Hall et al., 2020). Accessing the knowledge of nursing staff as frontline caregivers is critical, as they will carry out the new protocol and ensure adherence to established protocols. Clinical educators or trainers within the organization can provide valuable support by conducting training sessions (NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan) to prepare staff members adequately.

Additionally, the involvement of the quality improvement team ensures ongoing oversight and evaluation of the plan’s effectiveness, allowing for timely adjustments to optimize outcomes (Hall et al., 2020). Facilities management personnel contribute to the setup of the designated medication administration room, ensuring it meets the required standards.

Furthermore, collaboration with the IT department can streamline the integration of technology-based solutions, enhancing medication safety. To support these efforts, obtaining resources such as training materials, equipment, signage, and visual aids is crucial for effectively communicating and implementing the plan. Through the collaborative utilization of existing personnel and resources and the acquisition of necessary materials, the organization can successfully address the patient safety issue and improve patient outcomes.

Conclusion – NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan

The root-cause analysis highlights the multifaceted nature of diagnostic errors, emphasizing the need for a systematic approach to address underlying issues.  Applying evidence-based strategies, including standardized protocols, interdisciplinary collaboration, and cognitive bias mitigation, healthcare organizations can mitigate diagnostic errors and enhance patient safety. Furthermore, implementing a safety improvement plan focused on minimizing interruptions during medication administration demonstrates a proactive approach to addressing patient safety concerns. Leveraging existing organizational personnel and resources, coupled with necessary investments in training and materials, ensures the successful implementation of these initiatives, ultimately leading to improved patient outcomes and a safer healthcare environment.

References

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: Martin-Delgado, J., Martínez-García, A., Aranaz-Andres, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How Much of Root Cause Analysis Translates to Improve Patient safety. a Systematic Review. Medical Principles and Practice, 29(6), 524–531. https://doi.org/10.1159/000508677

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: Jussupow, E., Spohrer, K., Heinzl, A., & Gawlitza, J. (2021). Augmenting Medical Diagnosis Decisions? An Investigation into Physicians’ Decision-Making Process with Artificial Intelligence. Information Systems Research, 10.1287/isre.2020.0980(isre.2020.0980). https://doi.org/10.1287/isre.2020.0980

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: Gleason, K. (2022, March 7). Case: A Nurse’s Role in Preventing Diagnostic Error. Blog.thesullivangroup.com. https://blog.thesullivangroup.com/case-a-nurses-role-in-preventing-diagnostic-error

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: Jawad Al-Khafaji, & Sarah Mossburg. (2023). Improving Diagnostic Safety and Quality. Psnet.ahrq.gov, /improving-diagnostic-safety-and-quality(perspective/improving-diagnostic-safety-and-quality). https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administrationsafety by reducing distractions and interruptions. Journal of Nursing Care Quality, 35(4),

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Improvement Plan: E58-E62. https://doi.org/10.1097/NCQ.0000000000000473Hall, K. K., Shoemaker-Hunt, S., Hoffman, L., Richard, S., Gall, E., Schoyer, E., Costar, D., Gale, B., Schiff, G., Miller, K., Earl, T., Katapodis, N., Sheedy, C., Wyant, B., Bacon, O., Hassol, A., Schneiderman, S., Woo, M., LeRoy, L., & Fitall, E. (2020). Diagnostic Errors. In www.ncbi.nlm.nih.gov. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555525/

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