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Pages:
4 pages/≈1100 words
Sources:
5 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Research Paper
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 20.74
Topic:

Root-Cause Analysis & Safety Improvement Plan: Pediatric Weight Errors

Research Paper 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 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
Nursig 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].
Additional Requirements
Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to current APA style.

Research Paper Sample Content Preview:

Root-Cause Analysis and Safety Improvement Plan
Your Name
School of Nursing and Health Sciences, Capella University
NURS4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year
Root-Cause Analysis and Safety Improvement Plan
Pediatric weight errors during emergency care and subsequent wrong dose prescription are critical issues. It can lead to life-threatening medical conditions or even deaths in the worst scenarios. According to a recent assessment, 9% of pediatric dose administration errors are attributable to weight errors (Hirata et al., 2017). Even though pediatric weight errors are low in emergency conditions, it is considered a high-risk error due to its grave consequences for the patients (Hirata et al., 2017). The vitality of the issue is evident from the fact that the error is relevant to the age group under five years, which is already vulnerable and reactive to slight deviations in administration. Therefore, the chances of surfacing severe health issues as a result of the wrong prescription of dose are higher in that particular age bracket as compared to its older counterparts (Hirata et al., 2017). Therefore, it is essential to bring the issue into the spotlight and take strategic measures to avoid it.
Analysis of the Root Cause
The research and personal observation indicate that the issue of pediatric weight error is attributable to several critical factors. I have witnessed a case where a five-month-old kid was brought to the hospital and diagnosed with colic as the main cause of crying. The physician checked the dispensary reading of weight, which read 4 kilograms. The doctor prescribed eight drops of a routinely prescribed syrup. However, he was suspicious of the reading. Fortunately, before the patient left, he brought the kid to the scale and double-checked himself to find that the concerned staff had used the wrong unit (kilograms instead of pounds). He chastised the staff and reduced the dose to 4 drops.
The research is in line with this observation. It is found that the dependency on human input is the leading cause of weight error (Hirata et al., 2017). According to Hagedorn et al. (2017), confusion between pounds and KG is the leading cause of all the cases of weight errors, with a 28% attribution rate. The second most potential cause of the problem is the wrong placement of decimal. These two problems are critical since the physicians, in usual arrangement, have to rely on the information received from the paramedical staff. Therefore, both types of human error can lead to under or overdose prescriptions.
Another potential cause of the weight-based error is the inaccuracy shown by parents in reporting the actual weight of their kids to the physician. This leads to the manipulated perception of weight by the physician and subsequently wrong dispensing of the dose (Hirata et al., 2017). Even though the existing literature scarcely deals with attributing the parents' inability to report their kids' weight accurately, it is presumably rooted in wrong expectations or extrapolation. For example, if the baby's weight grows by one kg in a week, the parents may think that it will continue to grow at a steady rate of one kg per week, which may not be the case. At the ...
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