4020- Assessment 4 – Improvement Plan Tool Kit Sample
Improvement Plan Tool Kit
Your Name
School of Nursing and Health Sciences, Capella University
NURS-FPX4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year
Allison, D., & Peters, H. (2021). The need for root cause analysis (RCA). Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety, 3-10. https://doi.org/10.1201/9781003188162-2
The book adheres to a well-established training framework, incorporating practical illustrations and activities, with the aim of instructing healthcare practitioners and students on the principles of proficient and triumphant Root Cause Analysis (RCA) in order to eradicate patient damage. The present publication examines the necessity of RCA within the healthcare industry, offering pragmatic guidance for its effective implementation. The text covers the appropriate utilization of RCA, the development of efficient RCA action plans, and strategies for mitigating typical RCA failures. The curriculum for RCA training is also encompassed. The publication is important as it comprises those who hold leadership positions in the field of patient harm events, as well as leaders, students, and patient safety advocates who possess a keen interest in expanding their understanding of RCA within the healthcare domain. The resource highlights the significance of incorporating lessons from negative incidents into an organization’s safety culture. The publication has also prioritized the client as the focal point and acknowledge the significance of conducting thorough incident investigations for caregivers. The materials effectively prioritize a systems-based approach to medical errors, highlighting the significance of accurately identifying the underlying cause of an incident and establishing a proactive strategy to prevent its recurrence.
Cooper, E. E. (2017). Nursing students’ perception of safety in clinical settings: From the quality and safety officer. Journal of Nursing Education and Practice, 7(10), 91. https://doi.org/10.5430/jnep.v7n10p91
The article is useful as it provides information regarding the prioritization of teaching strategies aimed at enhancing patient safety as one of the central focus for nurses in reducing medication errors. The article also examines the utilization of error reporting methods by student nurses within the clinical environment, focusing on the findings of a study conducted by the Quality and Safety Officer at a School of Nursing and Health Professions. The study is important as it provides a comprehensive analysis of the utilization of safety tools and the perception of safety concerns in clinical environments by pelicensure baccalaureate nursing students. The responses indicate that nursing students encounter difficulties when it comes to reporting errors and near miss situations. The article is useful as it highlights evidence of challenges in error reporting among nursing students, but it also suggests that ensuring patient safety remains a paramount concern for the nursing student.
Hannan, J., Sanchez, G., Musser, E. D., Ward-Peterson, M., Azutillo, E., Goldin, D., … Foster, A. (2019). Role of empathy in the perception of medical errors in patient encounters: a preliminary study. BMC Research Notes, 12(1). doi:10.1186/s13104-019-4365-2
According to the article, empirical evidence shows that the presence of empathy among healthcare practitioners is associated with a reduction in the occurrence of medical errors. Medical errors have a significant impact on both patient outcomes and the well-being of healthcare personnel. Hence, the objective of this study was to establish the correlation between patients’ assessment of healthcare providers’ empathy, their intention to comply with treatment, and their perception of medical errors committed. Based on the study, the article shows that there is no significant association found between the provider’s empathy and the intention to follow-up with recommendations or return to the provider. Patients who received treatment from clinicians with high empathy did not exhibit greater treatment adherence compared to those who rated their provider with poor empathy. However, these patients were less likely to accurately recognize medical errors. The impact of providers’ empathy on patients’ perception of medical errors was found to be significant. The findings of the study is important as it emphasizes the necessity for healthcare curricula to incorporate the connection between empathy and the perception of medical errors, as well as the potential legal ramifications associated with this relationship.
Introduction to the PROACT® root cause analysis (RCA) work process. (2016). Root Cause Analysis, 25-38. https://doi.org/10.1201/b10988-5
The article posits that Root Cause Analysis (RCA) is a systematic approach employed for the examination of significant unfavorable events. RCA, originally designed for examining industrial accidents, has recently gained extensive usage as an error analysis technique in the healthcare sector. An essential principle of RCA is to pinpoint fundamental issues that heighten the probability of errors, but refraining from fixating on particular blunders. The Root Cause Analysis (RCA) methodology employs a systems approach to detect both active mistakes, which occur at the interface between humans and a complex system, and latent errors, which are hidden flaws within health care systems that contribute to adverse occurrences. It is a highly prevalent retrospective technique for identifying safety risks. RCAs often adhere to a predetermined process that commences with the gathering of data and the reconstruction of the incident in question through the examination of records and interviews with participants. A team comprising individuals from various fields should subsequently conduct a study of the chronological progression of events that culminated in the error. The analysis is important as it ascertains the manner in which the event transpired (by identifying active errors) and to determine the underlying causes of the event (by systematically identifying and analyzing latent errors). The primary objective of RCA is to proactively mitigate future harm by eradicating the underlying flaws that frequently contribute to unfavorable events.
Johnson, A. H., & Benham‐Hutchins, M. (2020). The Influence of Bullying on Nursing Practice Errors: A Systematic Review. AORN Journal, 111(2), 199-210. doi:10.1002/aorn.12923
This article analyses workplace bullying as being a significant concern within the nursing profession, as it has the potential to impact a nurse’s inclination to engage in medication errors. This comprehensive study investigates the impact of bullying behaviors on nursing practice errors. The study specifically address bullying among nurses in various healthcare settings, such as operating rooms, emergency departments, and acute inpatient and critical-care units. According to the study, nurses acknowledge that bullying has an impact on nursing practice errors and patient outcomes, however the specific processes are not yet fully understood. The study is important as it calls for further investigation to clarify the impact of bullying on medication errors in nursing practice and the resulting outcomes for patients.
Kremer, M. J., Hirsh, M., Geisz-Everson, M., Wilbanks, B. A., Clayton, B. A., Boust, R. R., & Jordan, L. (2019). Preventable Closed Claims in the AANA Foundation Closed Malpractice Claims Database.
This articles shows that Medical errors are one of the primary variables that contribute to patient mortality in the United States, causing around 400,000 preventable deaths each year among patients who are admitted to hospitals. Despite the progress made in enhancing patient safety in anaesthesia, adverse consequences continue to occur. This study utilized thematic analysis to examine anaesthesia closed claims associated with preventable disease and mortality. A total of 123 closed malpractice claims files, obtained from the closed claims database of the American Association of Nurse Anaesthetists (AANA) Foundation, were found to contain instances that may have been prevented by the Certified Registered Nurse Anaesthetist in question. The unnecessary closed claims were associated with many causes, including breaks in communication, violations of the AANA Standards for Nurse Anaesthesia Practice, and errors in decision-making.
Lewis, K. A., Ricks, T. N., Rowin, A., Ndlovu, C., Goldstein, L., & McElvogue, C. (2019). Does Simulation Training for Acute Care Nurses Improve Patient Safety Outcomes: A Systematic Review to Inform Evidence‐Based Practice. Worldviews on Evidence-Based Nursing, 16(5), 389-396. doi:10.1111/wvn.12396
This study investigates the impact of acute care registered nurse (RN) simulation trainings on patient safety improvements. A comprehensive search was conducted across five Internet databases to identify studies published between October 2018 and the present, which investigate the impact of registered nurse (RN) simulation trainings on patient safety outcomes within the adult acute care context. Seventy-five percent of the research utilized high-fidelity scenarios that were locally produced and focused on high-risk but rare incidents. A total of five studies, accounting for 42% of the sample, included participants from various academic fields in the scenarios and/or outcome evaluations. Indicators of outcome were obtained through self-reporting, direct observation, or clinical assessment. Enhancements in patient safety outcomes were observed across all studies included in this evaluation. The variability in results among different groups of registered nurses (RNs) remains uncertain due to inadequate reporting of gender, ethnicity/race, and age. The results provide evidence in favor of conducting simulation training research studies to investigate patient safety outcomes and the utilization of simulation training and research among acute care registered nurses (RNs). Further rigorous study is required to substantiate this field. Future research endeavors should encompass the inclusion of descriptors that effectively characterize the sample, such as age, gender, education level, type of nursing degree, ethnicity or race, or years of experience. Additionally, it is recommended that these studies incorporate interdisciplinary teams and evaluate a diverse range of outcome measure types, including self-report, direct observation, and clinical outcomes, both in close proximity and at a distance from the simulation. Furthermore, it is advised that these studies employ standardized scenarios, validated outcome measure instruments, and standardized debriefing tools.
Machen, S., Jani, Y., Turner, S., Marshall, M., & Fulop, N. J. (2020). Erratum to: The role of organizational and professional cultures in medication safety: a scoping review of the literature. International Journal for Quality in Health Care. doi:10.1093/intqhc/mzz136
This scoping review aims to examine the existing body of knowledge about the influence of organizational and professional cultures on medication safety. The objective is to enhance our comprehension of ‘cultures’ in pharmaceutical safety and establish a foundation of evidence to influence governance structures. The databases that were searched include ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO, and SCOPUS. The inclusion criteria encompassed original research and gray literature articles produced in the English language, which examined the influence of culture on medication safety within organizational or professional contexts. The inclusion criteria specifically targeted nursing, medical, and pharmacy professions. Exclusion criteria encompassed articles that failed to provide a conceptualization of the term ‘culture’ or neglected to address its impact. The authors, title, location, techniques, medication safety focus, professional group, and role of culture in medication safety were the characteristics for which data were extracted. The study highlighted four primary themes that had an impact on medicine safety: professional identity, apprehension of legal action and penalties, hierarchical structures, and the need to adhere to established cultural norms. Occasionally, the term ‘culture’ was employed in a vague and capricious manner, such as as a metaphor for enhancing medicine safety, without sufficient emphasis on its practical implications. The influence of organizational and professional cultures on pharmaceutical safety is significant. Gaining insight into the significance of different cultures can contribute to the formation of local government structures and the formulation of interventions that consider the influence of these cultural elements.
Olds, D., & Dolansky, M. A. (2017). Quality and safety research: Recommendations from the quality and safety education for nursing (QSEN) institute. Applied Nursing Research, 35, 126-127. https://doi.org/10.1016/j.apnr.2017.04.001
The article looks at the issue of patient injury due to medication error as a global healthcare dilemma leading to detrimental consequences for patients across the globe. Engaging in an international learning collaboration facilitated the acquisition of knowledge and understanding among participants, enabling the development of evidence-based approaches to enhance the quality and safety skills in nursing. To document the results of a global educational partnership centered on enhancing patient safety through the utilization of the Quality and Safety Education for Nurses competency framework. An international learning collaborative was established by a consortium of nursing faculty from across the world. This consortium developed instructional methodologies for both an online pre-workshop and a 10-day in-person experience. The participants of this initiative consisted of 21 undergraduate and graduate nursing students from six different nations. The confidence levels of participants in their patient safety competence were assessed by a retrospective pre-test post-test survey. This survey utilized the health professional education in patient safety survey and content analysis of daily reflective writings. The statistical analysis demonstrated a significant improvement in student confidence levels across all eight categories of safe practice when comparing pre- and post-education (p < 0.05). The skills of Quality and Safety Education for Nurses and a new cultural understanding were expressed in two main themes: reactions to shared learning experiences and shared areas of learning and growth. The article is important as it focuses on international collaborative learning as an initiative has provided evidence that cross-border learning opportunities have the potential to facilitate the global advancement of quality and safety outcome objectives.
Starmer, A. J., Schnock, K. O., Lyons, A., Hehn, R. S., Graham, D. A., Keohane, C., & Landrigan, C. P. (2017). Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Quality & Safety, 26(12), 949-957. doi:10.1136/bmjqs-2016-006224
According to the article, communication problems during handoff are a primary cause of sentinel occurrences. The article assesses the effects of a handoff enhancement initiative on nurses. The intervention known as the I-PASS Nursing Handoff Bundle encompassed various components, including educational instruction, the implementation of a vocal handoff I-PASS mnemonic, and the provision of visual materials to enhance reinforcement and long-term viability. Handoff direct observation and time motion workflow assessment methods were developed in order to evaluate two major aspects: (1) the quality of verbal handoff, which encompasses the frequency of interruptions and the presence of essential handoff data pieces; and (2) the duration of handoff and other workflow activities. The introduction of I-PASS was linked to enhancements in verbal handoff communications, encompassing the incorporation of sickness severity assessment, comparison between preintervention and postintervention, patient summary, to-do list, and the provision of an opportunity for the introduction of the I-PASS Nursing Handoff Bundle resulted in significant enhancements in the verbal handoff procedure, while leaving the nursing workflow unaffected. The article is important as it looks at the potential impact of implementing I-PASS for nurses lies in its ability to effectively mitigate medical errors and enhance patient safety.
Tobiano, G., Bucknall, T., Marshall, A., Guinane, J., & Chaboyer, W. (2015). Patients’ perceptions of participation in nursing care on medical wards. Scandinavian Journal of Caring Sciences, 30(2), 260-270. doi:10.1111/scs.12237
Article looks at active involvement of patients as being advantageous for the patient and is a fundamental principle of patient-centered treatment. Patients possess a strong belief in their capacity to mitigate errors, hence potentially assuming a crucial role in addressing the prevalence of adverse events within hospital settings. The study reveals presence of four distinct types. Initially, the act of valuing involvement demonstrated the patients’ eagerness to engage, perceiving it as a valuable undertaking. Furthermore, the act of exchanging intelligence served as a means of active engagement, facilitating the construction and dissemination of patients’ knowledge among healthcare practitioners. Furthermore, being vigilant was a form of engagement in which patients actively monitored their healthcare, demonstrating a vigilant attitude towards their own well-being. Furthermore, the presence of power imbalance was evident as patients perceived limitations on their options for active involvement. Establishing meaningful nurse-patient interactions, which involve the exchange of knowledge, is essential in order to empower patients to actively engage. Providing patients with information about the repercussions of not participating can inspire them, while nurses can get advantages from receiving training on patient-centered methodologies. Subsequent investigations should focus on strategies to enhance patient motivation and provide avenues for active engagement.
Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022). Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: A retrospective study of medical records. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08864-9
According to the study, medication errors are classified as prevalent medical errors that have the potential to cause irreversible harm to patients and impose significant financial burdens on the healthcare system. In order to effectively prevent pharmaceutical errors, it is crucial to possess a comprehensive comprehension of the frequency of such errors and the various elements that contribute to their occurrence. This study aimed to examine the frequency and categories of medication errors among nurses working in a hospital located in northern Iran. Assessing the frequency and categories of medication errors, as well as identifying the variables that contribute to them, enables the implementation of more focused therapies. The study’s findings suggest that the implementation of nurse training, the adoption of an evidence-based care strategy, and the establishment of effective interaction and coordination between nurses and pharmacists within the hospital setting can significantly contribute to the reduction of medication errors among nurses. Nevertheless, additional investigation is required to assess the efficacy of interventions aimed at mitigating the occurrence of pharmaceutical mistakes.
References
Allison, D., & Peters, H. (2021). The need for root cause analysis (RCA). Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety, 3-10. https://doi.org/10.1201/9781003188162-2
Cooper, E. E. (2017). Nursing students’ perception of safety in clinical settings: From the quality and safety officer. Journal of Nursing Education and Practice, 7(10), 91. https://doi.org/10.5430/jnep.v7n10p91
Hannan, J., Sanchez, G., Musser, E. D., Ward-Peterson, M., Azutillo, E., Goldin, D., … Foster, A. (2019). Role of empathy in the perception of medical errors in patient encounters: a preliminary study. BMC Research Notes, 12(1). doi:10.1186/s13104-019-4365-2
Introduction to the PROACT® root cause analysis (RCA) work process. (2016). Root Cause Analysis, 25-38. https://doi.org/10.1201/b10988-5
Johnson, A. H., & Benham‐Hutchins, M. (2020). The Influence of Bullying on Nursing Practice Errors: A Systematic Review. AORN Journal, 111(2), 199-210. doi:10.1002/aorn.12923
Kremer, M. J., Hirsh, M., Geisz-Everson, M., Wilbanks, B. A., Clayton, B. A., Boust, R. R., & Jordan, L. (2019). Preventable Closed Claims in the AANA Foundation Closed Malpractice Claims Database.
Lewis, K. A., Ricks, T. N., Rowin, A., Ndlovu, C., Goldstein, L., & McElvogue, C. (2019). Does Simulation Training for Acute Care Nurses Improve Patient Safety Outcomes: A Systematic Review to Inform Evidence‐Based Practice. Worldviews on Evidence-Based Nursing, 16(5), 389-396. doi:10.1111/wvn.12396
Machen, S., Jani, Y., Turner, S., Marshall, M., & Fulop, N. J. (2020). Erratum to: The role of organizational and professional cultures in medication safety: a scoping review of the literature. International Journal for Quality in Health Care. doi:10.1093/intqhc/mzz136
Olds, D., & Dolansky, M. A. (2017). Quality and safety research: Recommendations from the quality and safety education for nursing (QSEN) institute. Applied Nursing Research, 35, 126-127. https://doi.org/10.1016/j.apnr.2017.04.001
Starmer, A. J., Schnock, K. O., Lyons, A., Hehn, R. S., Graham, D. A., Keohane, C., & Landrigan, C. P. (2017). Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Quality & Safety, 26(12), 949-957. doi:10.1136/bmjqs-2016-006224
Tabatabaee, S. S., Ghavami, V., Javan-Noughabi, J., & Kakemam, E. (2022). Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: A retrospective study of medical records. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08864-9
Tobiano, G., Bucknall, T., Marshall, A., Guinane, J., & Chaboyer, W. (2015). Patients’ perceptions of participation in nursing care on medical wards. Scandinavian Journal of Caring Sciences, 30(2), 260-270. doi:10.1111/scs.12237
