Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan

• PRINT
• 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 pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.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.Demonstration of Proficiency
  By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
  • Competency 1: Analyze the elements of a successful quality improvement initiative.
    • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
    • Create a viable, evidence-based safety improvement plan for safe medication administration.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
  • Professional Context
    Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.Scenario
    For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:
  • The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
  • The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
  • 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 concern of medication administration safety 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 to 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 patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
  • Create a feasible, evidence-based safety improvement plan for safe medication administration.
  • Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
  • Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.
  • Assessment 2 Example [PDF].

more effective learning and application of scientific concepts.

PART 1: Head out into the Santa Barbara area and find an animal that you don’t often see. 

The animal must NOT be a pet or a human. 

Snap a picture of your animal and take note of when/where you discovered it.

 Figure out what Phylum the animal belongs to by Monday, November 22nd at 11:45 PM.

PART 2: Complete the writing prompt below and upload to Eli Review by Wednesday, November 24th at 11:45 PM.

Writing Prompt:

You are an animal biologist and are gearing up to conduct diversity surveys in the Santa Barbara area. These surveys require identifying and counting animal species found in specific areas around town to characterize local biodiversity.

 Before you start your controlled surveys, you decide to spend a few days observing animals in the area to get a sense of what variety of species you are likely to come across.

 To document these species, you snap a photo and keep notes of when and where you found them.

While out in the field searching for as many different animal species as you can, you are approached by a journalism student preparing a story for the UCSB Current about research on campus. 

You get to talking about your study and the journalism student asks to feature your work in her article.

 As part of the article, she asks you to prepare a brief explanation of why you are studying local biodiversity and why the broader UCSB community should care about your study.

Your explanation should be 350-400 words (about one page). 

This first draft should take about 60-90 minutes to write.

 Your role here is to write as an informed biologist to a broad community of students/profs/staff with various expertise and backgrounds. 

Your language should be straightforward and as uncomplicated as possible. You should explain the vocabulary you think is critical as the bolded words in sections of your textbook does.

Your explanation should cover the following key sections and points:

Introduce the topic of biodiversity and provide an example of the importance of one of the animals you discovered in your pre-surveys. 

This section should include:

1. A definition of biodiversity (1-2 sentences).

2. Use the categories of species values to explain the value of biodiversity (2-3 sentences). 

Species with direct use values are those that provide various goods or products directly to humans (typically linked to economic value) such as food, materials, and medicine.

Species with indirect use values include those with cultural and spiritual value and ecological value.

 Cultural and spiritual value represents species that inspire and stimulate technological innovations, contribute to recreation, are intrinsically beautiful/strong/scary/intriguing, or play a role in literature or myths. 

Ecological value represents the role that species play in their ecosystem — this can be the most difficult to identify and represents how a species contributes to and supports other species in its habitat. For example, does the species provide an “ecosystem service” such as pollination? Does it reduce pest populations? Aid in water purification?

3. An explanation of the indirect and/or direct value of one of the animals you found while conducting your pre-surveys. 

For this, head out into SB and find an animal that is NOT a pet or a human. 

It can be an animal that you find on campus, on the beach, close to your home – anywhere local! It could be an animal that UCSB students commonly see, or a rarer species.

Make it personal by describing the importance of biodiversity in our backyard. This section should include:

4. A description of the specific indirect and/or direct costs associated with losing your example animal species from the local ecosystem.

5. A conclusion in which you imagine how the broader UCSB community may be impacted by the loss of this species from the Santa Barbara area. 

This will help to make your article personal and relevant to the community.

Additional OPTIONAL reading that provides background on what biodiversity is and why it is important:

Article from the Guardian:

Article from the American Museum of Natural History: