NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Instructions

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue in a health care setting of your choice as well as a safety improvement plan.

Introduction

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.

Scenario – 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 safety quality issue presented in your Assessment Supplement PDF in Assessment 1. 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, provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] template 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 specific patient safety issue in an organization.

• Apply evidence-based and best-practice strategies to address the safety issue.

• Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.

• Identify organizational resources that could be leveraged to improve your plan.

• Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Solution: NURS-FPX4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Analysis of the Root Cause

Healthcare-associated pressure ulcers (HAPUs) are a common patient safety issue in healthcare settings. These ulcers develop due to prolonged pressure or/ and shear on the skin, mostly over bony prominences, impairing blood flow to the skin and underlying tissue, and causing skin breakdown, often affecting immobile or critically ill patients (Al-Mansour et al., 2020). HAPUs affect approximately 2.5 million Americans every year and are major causes of complications including serious infections, morbidity, increased costs of care from prolonged hospitalizations and readmissions, and even mortality (Agency for Healthcare Research and Quality, 2024). HAPUs are preventable and thus, the a need for healthcare organizations to implement proactive measures that aim at preventing and reducing rather than waiting until the ulcers have developed to treat them. A root-cause analysis (RCA) is an important tool for enhancing patient safety as it explores the causative/ contributory factors, identifies targeted interventions, and proposes a quality improvement plan to reduce HAPU incidence (Forkuo-Minka et al., 2024). This paper includes an RCA for a HAPU incident that occurred in our organization’s intensive care unit (ICU). Includes the root cause analysis, evidence-based strategies, a safety improvement plan, and organizational resources needed for the plan.

Root Cause Analysis

            One middle-aged male admitted to the hospital’s ICU following a serious motor vehicle accident developed a stage 3 HAPU over the sacral area after a two-week hospitalization period. The ulcer was not detected until in the advanced stages. It was detected by the patient’s sister who using her experience as a nurse in a long-term care facility, decided to check his kin to ensure his wellbeing, only to realize he had an advanced-stage ulcer that would require aggressive wound care and prolonged hospitalization. The sister immediately advocated for the patient, demanding immediate consultation with the attending physician and wound care nurse. This issue significantly affected the patient whose recovery was delayed, resulting in the need for additional treatment, prolonged stay, risk of infection, and pain. The sister threatened to sue the hospital if they did not take appropriate measures to treat him. The hospital had to incur increased expenses in treating the patient and even reimbursement penalties as HAPUs are preventable. Its reputation was also injured as the patient and his family were dissatisfied with….Click the paypal icon to purchase full solution for $10

Related: (Solution) NURS-FPX4020 Assessment 3 Improvement Plan In-Service Presentation