Redo Assessment 3-Class 3

This is a redo Assessment. I receive a 42% on Assessment 3.  Assessment 3 is a PowerPoint assignment. I have also attached teacher comments as to why I received 42% it is imperative that you comment, so you don’t make the same mistakes.
Please read instructions and I have attached the powerpoint that I got a 42% on. 

I received a 42% on this assessment, so please read

Scenario

, Instructions and Additional Requirements.

For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2. I have attached Assessment 2 and I received a 100% on that assessment.

Scenario

For this assessment it is suggested you take one of two approaches:

1. Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, OR

2. Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.For this assessment:

Instructions

The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at ;an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your presentation 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.

· List the purpose and goals of an in-service session focusing on safe medication administration for nurses.

· Explain the need for and process to improve safety outcomes related to medication administration.

· Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.

· Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.

· Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

There are various ways to structure an in-service session below is just one example:

· Part 1: Agenda and Outcomes.

. Explain to your audience what they are going to learn or do, and what they are expected to take away.

· Part 2: Safety Improvement Plan.

. Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.

. Explain why it is important for the organization to address the current situation.

· Part 3: Audience’s Role and Importance.

. Discuss how the staff audience will be expected to help implement and drive the improvement plan.

. Explain why they are critical to the success of the improvement plan focusing on medication administration.

. Describe how their work could benefit from embracing their role in the plan.

· Part 4: New Process and Skills Practice.

. Explain new processes or skills.

. Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.

. In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.

· Part 5: Soliciting Feedback.

. Describe how you would solicit feedback from the audience on the improvement plan and the in-service.

. Explain how you might integrate this feedback for future improvements.

Additional Requirements

· Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be 10–15 slides.

· Speaker notes: Speaker notes should reflect what you would actually say if you were delivering the presentation to an audience. Another presenter would be able to use the presentation by following the speaker notes.

· APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.

· Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.

I received a 42% on this assessment, so please read ALL teacher comments as she has given me feedback on assessment.

Teacher Comment: This part of the scoring guide was not addressed in the presentation. Usually the second slide of a presentation lists goals and objectives. To reach a higher performance level, you needed to be specific on the goals and purpose of the in-service and how they would address medication errors. In addition, to reach a distinguished level, you needed to explain the relevancy of the goals and purpose to how the change from the education provided during the in-service would impact quality of care. Please be sure to address all areas in the scoring guide and follow the criteria listed. If you would like to discuss this with me, please feel free to contact me.

Teacher Comment: You briefly explained the need for and process to improve safety outcomes related to medication errors; however, the explanation of the relevance to the organization was not identified. The multi-year review of incidents your previously described was not included and could have served as the database for slides 2-3 in which causes of the errors were described. Please make sure to refer to the assessment rubric so not to miss any components to the criterion. I suggest that you focus on the distinguished level of the criterion while developing your assessment. This will ensure that you meet the course competencies. Please let me know if you have any questions.  

Teacher Comment: While you described how the role of the audience, you needed to explain just how important the audience’s role is to the success of the improvement plan to reduce medication errors. In addition, you could have described the type of communication required to promote a buy-in which was outlined in the scoring guide. Let me know if you have any questions

Teacher Comment: The section of the scoring guide was not addressed in the paper. You were to create some resources and activities to reduce medication errors, such as presenting a case scenario of one or two commonly found incidents and explain their relevance to developing the skills or understanding the process to enhance the audience’s comprehension of the safety improvement plan. In addition, you could have supplied notes to the audience to enhance their understanding of the process as outlined in the scoring guide. Please be sure to follow the criteria in the scoring guide.

Teacher Comment: While you presented a presentation to nurses about a safety improvement plan, there was a lack of ability to communicate in a informative manner where expectations were clearly identified and where feedback was solicited for future communication strategies.  The slides did not consistently reflect your plan. The slides were difficult to read at times because of the font size and too much information on a slide. When developing a presentation please take into consideration that your stakeholders need to be able to read it from a distance of about 5 feet. I suggest that you have someone look at your slides from this distance to guide the font size on your slides. This will make a difference between a proficient and distinguished designation in this criterion. I hope that these suggestions help you prepare you for the many presentations you will conduct in your professional career. Thank you, for sharing it with me!

Running head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 1

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 9

Root-Cause Analysis and Improvement Plan

Capella University

October, 2020

Root-Cause Analysis

A Structured Root Cause Analysis (RCA) is becoming a key area of interest among health professionals. Hospitals are performing this to reduce surgical errors are some of its subspecialties. Recent research has helped in the RCA process and how effective they can implemented in the formal quality improvement projects (Charles et al, 2016). The purpose of an RCA is to design ways that will formally address the issues in an organization. This utilizes a methodology that helps in causal identification and development of corrective actions. In the case of reducing of medical errors, it will be on the root causes and contributing factors, actions can be developed to prevent recurring errors. The paper describes and analyzes medical errors and discusses evidence-based strategies to provide quality patient care in medical and surgical practice. It will define measures that intervene for planned success in patient safety and the success of the RCA.

Analysis of the Root Cause

The use of medication is a multifaceted process in a healthcare setting starting with the physician giving a prescription, nurses performing transcription, pharmacists dispensing, administration of the medication, and monitoring of patients. Medication errors are a primary cause of most deaths and unintended patient harm. According to Feleke et al., (2015), medication administration errors results in patient morbidity, unfavorable drug events, mortality, and increases the duration of hospital stay for the patients. Additionally, it increases healthcare costs for the healthcare system and the clinicians. According to IOM and joint commission, drug administration errors can be averted by evaluating the extent and the accompanying factors of drug administration errors. This will help improve the quality of patient healthcare.

Bearing in mind the adverse effects of medication administration errors in patients, a root-cause analysis on the medication administration errors cases reported over the years was conducted at the inpatient hospital unit. The analysis objective was to understand the causes of medication administration errors in inpatient patients in the hospital unit. A group of ten experts took the initiative to conduct the analysis; they included physicians, nurses, pharmacists, and quality and safety improvement staff. A team of registered nurses had done cases of medication administration errors that had been reported within the facility. All the medication administration error cases were described to be due to wrong prescription, medication labelling, miscommunication of order, wrong dosage, wrong dispensation, and poor communication between patients and physicians.

It was discovered that most of the medication errors occurred during the medication administration phase, when nurses had a lot of work to do due to understaffing. The experts reported that physician’s prescription was a significant cause of medication administration errors. They recorded that physicians prescribed the wrong dose, the wrong quantity, wrong indication, or even prescribed contraindicated drugs to a patient. Further, they noted that lack of prescribed drug knowledge, the recommended dosage, and the details of the patients contributed topmost of the prescription errors. The experts also reported that medication administration errors due to dispensation were mainly because pharmacists selected medications with the wrong strength or wrong drug mainly with medications bearing a similar name or drugs that look alike. For instance, drugs such as Lasix and Losec when handwritten, look alike.

The experts went through the reports and noted that approximately 24% of dispensing errors occurred in the inpatient section. Moreover, the medication administration errors reported in the inpatient hospital unit involving the nurses were primarily due to transcription errors (manual and electrical transcription of orders). In these omission errors, the nurses do not administer drugs due to specific reasons. According to their report, transcription errors involved incorrect medication, time, frequency, dose, oral order misunderstanding, oral orders not fed into the system, discrepant orders from the patient’s medication history, and incorrect scheduling of doses in manual administration record (Gorgich et al, 2016).

Application of Evidence-Based Strategies

. Organizations need to spell out, clearly, health guidelines regarding patient safety and medical errors. They need to ensure that accountability is reinstated on the hospitals and the health professionals (Scott & Henneman, E. (2017). Seamless need to develop appropriate systems that help in addressing medication errors. For instance, critically ill patients need more attention and often cause a burden to the limited staff. Separating the patients helps assign the need for urgency and critical care. It will minimize medical errors for those in a critical state.

According to Dall’Ora et al., (2016), physical exhaustion and emotional exhaustion contribute to the errors. The interruptions during medication administration increase the risk of medication errors (Berlin, 2017). The nurses need work and life balance to be better placed at being at their optimum. Staff engagement measures are one way of ensuring that their concerns towards patient safety and medical administration in these departments are prioritized. Medication administration errors are multifaceted issues, and solving them requires a multilateral solution.

Considering that all the reported medication administration errors occurred because of the errors in prescription phase, it is essential to install computerized physician order entry to reduce the incidences of the prescribing errors, which will avoid errors in the other phases. Besides, clinical decision support systems is another critical intervention that can be utilized to reduce medication errors (Gorgich et al., 2016). They help reduce medication errors by alerting and helping prescribers’ choices regarding therapeutic management, a period of drug therapy, allergy, laboratory test values, dose, frequency, and side effects, which are very vital to guarantee patient safety.

Using the clinical decision support systems are significant because they conduct the patient’s background check, provide timely information, and provide feedback on the cost and suitability of medications. Incorporating personal digital assistants is vital in reducing medication errors because several medication errors are because pharmacists and physicians lack the appropriate medication knowledge.

The personal digital assistants would help provide the physicians and the pharmacists with medication information required for prescribing, distributing, and counselling (Wang et al., 2015). It will also provide the physicians and pharmacists with access to the patient’s specific treatment profile, which is essential in reducing prescription and transcription errors. Additionally, modified medication and prescription charts and mobile clinical assistants can be used to reduce medication errors. Physicians can make their handwritten prescription legible, use automated dispensing machines, and use of smart devices when administering drugs intravenously.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Safety and quality improvement plan is an integral approach in helping healthcare professionals achieve maximum levels of safety performance. The improvement plan comprises of two-split approaches, i.e., enhancing the efficiency and coordination of the healthcare professionals and implementing the physical modifications. First, the improvement plan aims at improving the knowledge of healthcare workers regarding medication errors, reporting, and avoiding them (Gorgich et al., 2016). In addition, due to the understaffing, the plan focuses on increasing the number of healthcare professionals to avoid overworking that causes burnout, which results in medication errors.

Second, the plan aims at ensuring there is proper communication between the healthcare professionals when medication is involved, which will help reduce the miscommunication issues (Wang, 2015). It is also crucial for the nurses to educate the patients on the medications and allow them to open up regarding their medical history, allergies etcetera. Third, the improvement plan aims at ensuring healthcare providers utilize evidence-informed practices. Finally, regarding the physical modifications, the plan focuses on the implementation of advanced medication administration technologies that minimize these medication errors.

Acquisition of knowledge is critical in health care. The nurses need to be trained to understand their changing roles in preventive care (Charles et al., 2016). They need to realize the ethical implications of medication error and their relative contribution to the same. They need to know the right procedures to undertake when reporting medication errors and how best the hospital serves its needs. Such improvement plans need the adoption of new EHR technologies. Hospitals need to train their workforce to adopt new technology.

Adopting new technology, such as EHR, helps identify medical errors and trace those liable for accountability. This will also build on the awareness of the reporting procedures and process. They also get informed on medication error reporting policies and systems within the organization reducing the excuses for ensuring accountability. Also, it is the role of the hospital to define work division. This minimizes work overload and disruptions during surgical operations. There need to be defined as guidelines targeting critical departments such as surgical. Training should focus on the implementation of policies and medication management for overall improvement in quality care. This should be implemented for over two months.

Existing Organizational Resources

For the program plans to be a success, the organization needs to set aside resources. This will require budgeting, which will target: increasing staffing, training measures, and purchase of up to date EHR software systems. Specialists need to be brought on board to assess the current needs of the organization. Also, the training and education of the staff need to be a continued measure of the organization. It allows them to improve their knowledge of patient safety and keep up with current standards of their practices in reducing medication errors. Accomplishing this plan will require approximately $50,000.

Conclusion

Performing an RCA process is all about identifying the consequence of events that led to

the event investigated. In this case, patient safety has been targeted to those in the surgical and transplant department. As a critical department in the healthcare setting, special consideration will be put in place in its complexities. The categories that will focus are human errors, communication, policies, and procedures leading to such issues. The goal of a sustained system should also give room for improvement. Elimination of medical errors promotes patient safety. Quality improvement measures are targeting surgical errors.

References
Berlin, L. (2017). Medical errors, malpractice, and defensive medicine: An ill-fated triad. Diagnosis, 4(3), 133-139. doi:10.1515/dx-2017-0007
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10(1), 20-20. doi:10.1186/s13037-016-0107-8
Dall’Ora, C., Griffiths, P., & Ball, J. (2016). Twelve-hour shifts: Burnout or job satisfaction? Nursing Times (1987), 112(12-13), 22-23.
Feleke, S. A., Mulatu, M. A., & Yesmaw, Y. S. (2015). Medication administration error: Magnitude and associated factors among nurses in ethiopia. BMC Nursing, 14(1), 53-53. doi:10.1186/s12912-015-0099-1
Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016;2015;). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 54448-54448. doi:10.5539/gjhs.v8n8p220
Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046.
Scott, S. S., & Henneman, E. (2017). Underreporting of medical errors. Medsurg Nursing, 26(3), 211.
Wang, H., Jin, J., Feng, X., Huang, X., Zhu, L., Zhao, X., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: A trend analysis during the journey to joint commission international accreditation and in the post-accreditation era. Therapeutics and Clinical Risk Management, 11, 393-406. doi:10.2147/TCRM.S79238

Improvement Plan In-Service Presentation

Root Cause Analysis
Quality improvement initiatives are critical in the health setting
The improvement plan tool kit aims at enabling nurses and health care setting in implementing safe and sustainable approaches towards patient safety.
The improvement plan will focus on medical errors in the surgical and transplant units
Over 98,000 death related cases are reported annually due to medical errors (Scott & Henneman, 2017).

Medical errors are categorized into time errors, dose errors, medication errors, and patient errors.
However, surgical units report dose errors as the most common error.
This result from communication inefficacies, poor staff management procedures, lack of appropriate systems in medical reporting and unclear guidelines towards patient safety
The behavioral determinant define how best health professionals adhere to the set ethical standards.
Maladministration or ignorance in a healthcare setting is leading factors towards medical errors.
This makes it paramount for nurses and other healthcare professionals to institute quality care (Scott & Henneman, 2017).
2

Root Cause Analysis
Root Cause Analysis is a Quality Improvement tool in health case initiatives
RCA process and how effective they can implemented in the formal quality improvement projects (Charles, 2016).
It utilizes a methodology that helps in causal identification and development of corrective actions
Reducing of medical errors requires establishing the root causes and contributing factors, and actions in preventing recurring errors.

The analysis aims to establish the leading causes of medical errors in the surgical departments.
Some of the obstacles identified include cultural norms, the burden in reporting measures, anxiety, poor feedback, time constraints, and selectivity of reporting (Charles, 2016).
Highly sensitive departments, such as surgical units, need to address such concerns separately with their special teams.
The team members involved will include the physicians, nurses, supervisors, quality improvement experts, and ancillary staff.
The time of completion would vary depending on the complexities
The designed time frame would be one to three months.
3

Improving Patient Safety Focusing on Medication Administration and Reducing Costs
The need to emphasize the ethical implications of medication error and their relative contribution to the same (Hammoudi et al., 2018).
Developing work policies that are set to ensure accountability of health professionals
Nurses are trained in how best to handle patient safety.
Ensure that staffing schedules are well managed to reduce cases of work overload and human errors.

Negligence on their part could result in the suspension of their licenses or even revocation of their practicing license (Hammoudi et al., 2018).
Hospitals need to train their workforce to adopt new technology.
EHR, helps identify medical errors and trace those liable for accountability
Her systems improve reporting measures allowing hospitals to act fast on cases of medical errors.
The nurses need to be trained to understand their changing roles in improved care (Charles et al., 2016).
The staff need to understand the need to coordinate their roles to reduce workload and improve communication to reduce interruptions
4

Nurse’s Role in Coordinating Care to Enhance Quality and Reduce Costs
They engage directly with patients across all units
They adhere to set safety guidelines for patient care and ethical measures (Hammoudi et al., 2018).
They report on effectiveness of measures towards patient safety (Dall’Ora et al., 2016)
They liaise with other health professionals in ensuring that patients recover and leave the hospital

Nurses role underpin those of patient safety
nurses are the primary care giver in hospitals
They deal directly with patients for preventive care
They are held liable for any issues related to patient care (Hammoudi et al., 2018).
It is up to them to set the precedence on ethical guidelines in for quality improvement plans
nurses have to be trained on their contribution towards reduced medical errors.
nursing practice needs clear scheduling to ensure that they perform their roles at optimum for reduce medical errors (Dall’Ora et al., 2016)
5

Implementation and Resource Management
The plan can be implemented by educating all healthcare professionals on patient safety and reducing medical errors (Hammoudi et al., 2018).
Specialized staff will be involved in the improvement plans i.e IT specialist
Purchasing of new equipment to replace the obsolete ones ]
Implementation new EHR systems that match with skills of the staff
The plan can be managed by identifying and noting the areas that need improvement and budgeting for them.

Implementing and managing the resources is essential in ensuring the objectives of the improvement plans are met.
There are various capital and human resources to be put into consideration for the implementation plans. This will entail educating and training of the staff to ensure that the plans align with their roles in patient safety. All health professionals need to understand their role in ensuring patient safety. A budget will be set aside for equipment and in setting up appropriate systems for the hospitals. These systems need to support
6

Evaluations
Reduced rates of deaths in surgical units as a result of medical errors
Nurses understanding their changing roles in improving patient safety
Reduction of adverse health events to patients receiving an organ transplant, surgery, or any other medication.
Improved and effective communication between healthcare professionals (Charles et al., 2016)
Reduced cases of conducting surgery and transplantation on wrong patients and wrong sites.

Evaluations are set to see how effective the plans are. There needs to be evaluation procedures in the reducing the cases reported from medical errors. the nurses need to understand and improve their knowledge towards patient safety. Evaluation needs to take consideration for the communication procedures. This may need the need of surveys to receive feedback on the implementation process. In essence , there needs to be a reduction in adverse health events on the side of the patients. Overall, this will reduce the medical errors reported and death that results from medication errors. Realizing all these will show that the plan was successful, and no resources were mismanaged.

7

Conclusion
Continuous improvement plans need to be at the core of the organization
A culture of change ensures that organization continue to establish root cause analysis of the existing barriers in healthcare
They need to put into consideration of the contribution of their staff in improved care in surgical units
Improvement initiative plans reflect the ethos of the organization

8

References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root
cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10(1), 20-20.
doi:10.1186/s13037-016-0107-8
Dall’Ora, C., Griffiths, P., & Ball, J. (2016). Twelve-hour shifts: Burnout or job satisfaction? Nursing Times
(1987), 112(12-13), 22-23.
Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why
nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046.
Scott, S. S., & Henneman, E. (2017). Underreporting of medical errors. Medsurg Nursing, 26(3), 211.