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

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Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

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Root Cause Analysis and Safety Improvement Plan 

Introduction each year, millions of patients in the United States experience harm because of the healthcare they receive (Gottula et al., 2024). Health care uses a vital tool, root cause analysis (RCA), to detect errors and prevent future mistakes before they occur. This paper will focus on an RCA undertaken after a near miss involving patient identification in a busy cardiac unit. The focus will be on analyzing the incident’s root cause, proposing evidence-based strategies for improvement, and leveraging existing resources to enhance patient safety.

Analysis of the Root Cause

The case involved a bedside nurse in a fast-paced cardiac unit who accidentally printed the wrong armband for a patient. This nurse was assigned five patients. Two white males aged 70 and 74 shared a similar first name, but the last names differed in spelling and rhyming. The patients were placed in adjacent rooms. Moreover, had the same diagnosis: Chronic Heart Failure and a history of Dementia. Both were receiving intravenous (IV) furosemide drips. Patient A lost their only IV site and was a difficult stick because of his thin and fragile skin.

The nurse took time to find a viable vein. The patient identification armband covered the only viable vein and had to be removed to insert a new IV line. After completing the task, the nurse, on her way to print the armband replacement, a Certified Nurse Assistant (CNA) approached her and reported that patient B was complaining of chest pain. The nurse took priority and assessed patient B.

The nurse assessed the pain level, placed the patient on oxygen, took Vital Signs, completed an EKG, and paged the provider for further orders. After addressing Patient B’s needs, the nurse mistakenly printed Patient B’s armband and placed it on Patient A. The phlebotomist was trying to draw labs of patient A and noticed the mismatch between the armband and the lab slip. The phlebotomist did the identification process by verifying the name and birth date and scanning the armband barcode and the laboratory-ordered slip; they did not match. Scan the barcode and verify the full names, birthdates, or MRN; this process is safe and prevents errors. (Aschenbrenner, 2023).

Factors Leading to Health Risks

This event took place because of several factors. First, the nurse printed the wrong armband for Patient A and placed it on Patient A’s arm without verification and double-checking. The phlebotomist detected the error before drawing labs. This scenario could have taken a different turn if the phlebotomist did not catch the error. The patient would have been at risk for serious harm. Patient B would not have been impacted indirectly. However, the error exposed both patients to risk because this was a near miss. None of them were affected. However, this incident highlighted how medication errors could prove fatal. The root causes of the error were the busy environment, interruptions, and not following proper patient identification protocols. Because the nurse was busy, she omitted to double-check the patient’s armband. Their similar names also increased patient identification errors. 

Application of Evidence-Based Strategies

Literature shows interruptions and high workloads increase patient identification errors (Aschenbrenner, 2023). Studies also highlight that nurses, especially those working in high-pressure environments, may skip verification steps to save time, increasing the risk of errors (Singh et al., 2024). Barcode scanning technology has been proved to reduce these errors, but it must be used correctly with consistency for patients’ safety (Aschenbrenner, 2023). Evidence-based strategies, such as incorporating policies that require double verification for patient identification, will help address this issue.

Two staff members, such as a nurse and CNA, would verify the patient’s full name, date of birth, and/or sometimes a medical record number (MRN) as a second identifier before applying an identification bracelet. Standardizing the process by having barcode scanning for patient identification can help reduce medical mistakes. Two identifiers should always verify the patient’s identity when providing care and services. The Joint Commission requires healthcare professionals to use two or more patient identifiers when labeling, delivering, and maintaining specimens. (Rodzewicz et al., 2024) Since this is a National Patient Safety Goal, The Joint Commission closely monitors healthcare institutions’ adherence to this requirement as they prepare medications and transfusions and transfer patients from unit to unit. (Rodzewicz et al., 2024) 

Safety Environment Plan

A safe environmental plan should focus on minimizing distractions for nurses as they care for patients and emphasize following proper patient identification protocols. This plan will include introducing a compulsory double-check policy for patient identification. Introducing no interruption time when nurses are engaged in critical tasks is essential as nurses engage in patient identification to avoid errors. Confirming verbally with a patient for identification with a colleague present should be mandatory. Emphasizing the importance of patient safety in continuous education while highlighting the risks of medical error would be part of the plan.

The preferred goals and outcomes are to reduce patient identification errors and increase staff members’ ability to follow safety protocols while avoiding medical errors. The barcode of the scanning system should be mandatory for better patient identification. All staff members, providers, nurses, nurse aides, phlebotomists, transporters, and other healthcare workers should practice double-verifying when providing care or services. During staff meetings and huddles, the organization’s leaders can highlight the importance of patient safety protocols. Adding more barcode scanners would be required to ensure they are readily available at every patient’s bedside. Workloads should be appropriate to ensure nurses have enough time to follow identification protocols without feeling rushed.

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

When a medical error or sentinel occurs, the Joint Commission mandates a standardized RCA process to determine the cause of medical mistakes. An RCA’s initial step is forming an interprofessional team to investigate and define the problem. After identifying the problem, the team evaluates systematic factors contributing to the error using a 24-question guide. This includes examining the systematic process, human factors, equipment malfunctions, environmental factors, uncontrollable external factors, organizational factors, staffing and qualifications, contingency plans, performance expectations, communication issues, and technology (Singh et al., 2024).

Throughout the process, the team collects data for the underlying causes and proposes and implements immediate changes so that a repeat sentinel event does not occur during the RCA process. For interventions, the team meets senior leadership and key stakeholders and determines if they are acceptable. “The Swiss Cheese Model.” is one model used to identify the levels at which errors occur. The four primary levels are unsafe acts, preconditions for unsafe acts, supervisory factors, and organizational influences. (Singh et al., 2024).

Sometimes, investigations among team members can be challenging. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints (Liepert, 2023). All team members need to be educated about RCA processes.

Existing Organizational Resources

The hospital’s existing healthcare staff and resources are vital for growing the improvement plan to address patient identification errors. The medical team comprises doctors, nurses, and administrative staff. This team is crucial in reviewing identification protocols and integrating these changes into daily practices. Their proficiency in validating patient data and executing identification procedures will confirm that the new approaches are evidence-based and patient-centered. Nurses will be accountable for communicating vital identification data to the healthcare team.

They certify that confirmations are organized and precise (Riplinger et al., 2020). The hospital’s quality improvement team will manage the plan’s rollout and observe patient safety outcomes. The team provides feedback to improve protocols as required. Employing the existing electronic health record system to integrate identification checklists and alerts will strengthen adherence to new procedures among all workers (Riplinger et al., 2020). This system encourages effective data sharing and accurate documentation to improve the patient identification procedure.

Additional support is vital for the plan’s efficacy in addressing patient identification errors. Validation of identification devices will be improved to enhance precision. Access to cutting-edge technologies like scanning and verification systems will support this effort. The hospital should prioritize constant education and training for healthcare experts on updated identification procedures and communication methods. Collaboration with external experts can bring additional skills to enhance outcomes. These developments and the hospital’s existing resources will help lessen identification mistakes and promote patient safety and care standards (Veen et al., 2020).

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

The American Nurses Association (ANA) highlights the significance of standardized nursing practices to avoid identification errors, stating that nurses should obey the nursing process. It includes evaluation, planning, intervention, and evaluation to maintain an organized approach to patient care. Nurses reduce errors and improve patient outcomes by following these principles. Efficient communication with other healthcare staff further reinforces their impact. The ANA highlights the need for constant education and skill development to ensure that nurses are experts in using modern tools and technologies (Christman & Ernstmeyer, 2021).

Conclusion

The root cause analysis is vital for finding and addressing patient safety issues. The error in this scenario was a near miss involving a patient identification error caused by human error, work environment factors, and not following identification protocols. By using evidence-based strategies such as double-checking patient identification and reducing interruptions, the healthcare environment will mitigate future risks of errors. These strategies will become part of organizational culture and help to improve patient care and safe practices.

References

Aschenbrenner, D. S. (2023). Nurse using barcode workaround leads to patient injury. American Journal of Nursing, 123(9), 21–21. https://doi.org/10.1097/01.naj.0000978136.01694.31

Christman, E., & Ernstmeyer, K. (2021, January 1). Nursing fundamentals. Nih.gov https://www.ncbi.nlm.nih.gov/books/NBK591808/ 

Gottula, J. L., Hope, E. R., Wood, T. A., Medla, S. A., Saunders, R. D., & Keyser, E. A. (2024). Rapid root cause analysis: Improving OBGYN resident exposure to quality improvement and patient safety curricula. Cureus, 16(3). https://doi.org/https://doi-org.library.capella.edu/10.7759/cureus.5688

Liepelt, S., Sundal, H., & Kirchhoff, R. (2023). Team experiences of the root cause analysis process after a sentinel event: A qualitative case study. BioMed Central health services research, 23(1)(1224). https://doi.org/https://doi-org.library.capella.edu/10.1186/s12913-023-10178-3

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

Riplinger, L., Jiménez, J. P., & Dooling, J. P. (2020). Patient identification techniques – approaches, implications, and findings. Yearbook of Medical Informatics, 29(1), 81–86. https://doi.org/10.1055/s-0040-1701984

Rodziewicz. (2024). Rodziewicz TL, Houseman B, Vaqar S, et al. Medical Error Reduction and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956 (B. Houseman, Ed.). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956

Singh, G., Patel, R. H., & Vaqar, S. (2024, January). Root cause analysis and medical error prevention. Treasure Island (FL). https://www-ncbi-nlm-nih-gov.library.capella.edu/books/NBK570638/

Veen, W., Taxis, K., Wouters, H., Vermeulen, H., Bates, D. W., Bemt, P. M. L. A., Duyvendak, M., Luttikhuis, K., Ros, J. J. W., Vasbinder, E. C., Atrafi, M., Brasse, B., & Mangelaars, I. (2020). Factors associated with workarounds in barcode‐assisted medication administration in hospitals. Journal of Clinical Nursing, 29(13-14), 2239–2250. https://doi.org/10.1111/jocn.15217