When patient safety is compromised, it is critical to get to the root of the issue in order to determine how to ensure patient safety and avoid risks in the future. Nurses can use analytical techniques to determine root causes related to various types of errors. Medication error is a typical error that can be subject to process improvement in general, and root cause analysis in particular. This process came out of NASA after the Space Shuttle Columbia disaster and has been adopted by the health care industry. This week, you analyze a case related to medication error, and you examine how root cause analysis is applied to prevent future error and formulate process improvement plans.
Students will: Analyze the composition of a root cause analysis team in relation to effective practice Critique the effectiveness of the performance improvement charts in identifying contributing factors Apply findings from a root cause analysis to prevent future errors Apply a quality improvement process to an improvement plan
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.
· Chapter 4, “Evaluating Performance” (pp. 73–110)
· Chapter 5, “Continuous Improvement” (pp. 111–130)
· Chapter 6, “Performance Improvement Tools” (pp. 131–162)
Note: Although these chapters are previously assigned readings, please review them in preparation for this week’s material.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby.
· Chapter 17, “Leading Change” (pp. 305–320)
· Chapter 23, “Conflict: The Cutting Edge of Change” (pp. 431–447)
Laureate Education (Producer). (2016a). Root cause analysis at Downtown Medical [Interactive file]. Baltimore, MD: Author.
Laureate Education (Producer). (2016b). RCA dramatization 1 [Video file]. Baltimore, MD: Author.
Note: The approximate length of this media piece is 4 minutes.
Case scenario involving medication error including pharmacy, physician, and nurse—interdepartmental collaboration.
Interactive media—students select options that generate chart based on choices
(Voiceover reads the document aloud—include a downloadable pdf).
Discussion: Root Cause Analysis
Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.
By Day 3
Post each of the following: Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA. Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming. Explain the team’s process in testing for and eliminating root causes that were not contributing. Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors. Identify the contributing factors, and discuss how to prevent this kind of error from occurring in the future.
Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level (see checklist)
Notes Initial Post: This should be a 3-paragraph (at least 350 words) response. Be sure to use evidence from the readings and include in-text citations.
Practice Experience: Stakeholder Analysis
The next step in the process is to begin identifying the challenges and impediments to implementing a quality improvement plan. In the analysis consider the individuals affected by the change as well as the cost of implementing the quality improvement plan.
By Day 4
Post a description of some of the proposed action steps for implementing improved practice, and explain where potential challenges might compromise your proposed improvement project. Describe what resources are needed for your solution, and explain whether or not those resources are cost-effective. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project, and share this information with your group.