NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Name

Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

In this assessment, we conduct a Root-cause Analysis (RCA) of the patient safety and quality issue at AdventHealth, Winter Park. The issue identified is inadequate pain management in healthcare settings, leading to poor patient outcomes and poor care quality. Through this RCA, we analyze the root causes of the scenario and present evidence-based best practices to address the quality and safety issues. This assessment establishes a safety improvement plan for the organization and elaborates on using organizational resources to implement the plan successfully.

Analysis of the Root Cause

The scenario is about inadequate postoperative pain management for Ms. Johnson following her hip replacement surgery at AdventHealth, Winter Park. The surgical procedure was completed successfully, and Ms. Johnson was moved to the postoperative care unit to recover. However, the problem stemmed because of the surgeon’s inadequate communication with the nursing staff about postoperative instructions for pain management. In the recovery unit, Ms. Johnson was placed under the supervision of a novice nurse. She complained of severe pain a few hours later, rating it at an 8 out of 10 on the pain scale. However, an insufficient and imprecise pain assessment was conducted due to unskilled nursing staff. Due to the incorrect assessment and inadequate communication regarding post-operative pain management orders, the patient received her pain medication late, leading to prolonged discomfort and an all-around stressful situation.

The relevant finding of the root-cause analysis presents that adequate communication between the surgeon and nursing staff must be regarding postoperative pain management orders. Moreover, nurses should perform timely and accurate pain assessments and administer them promptly to ensure patient comfort. Several elements influence the situation. While the environmental factors include the busy and high-stress atmosphere of the postoperative care unit, human factors include nurses’ lack of expertise and education.

Lastly, ineffective interaction and collaboration among healthcare providers are communication factors. The root causes of this issue appear to be the communication gap between the surgeon and nursing staff and lack of coordination (Atthayasai et al., 2023) among the nurses and pharmacists, which led to delayed administration of pain medication, compromising the overall quality of postoperative care. Additionally, novice nurses’ lack of experience and limited education in pain evaluation contributed to improper and incomplete pain assessment, resulting in patient discomfort and reduced satisfaction (Cao & Hull, 2021; Hämäläinen et al., 2022).

Evidenced-Based and Best Practice Strategies

The literature suggests several evidence-based best practices to address inadequate pain management as a quality and safety issue in healthcare settings. These strategies are best suited to combat the communication, coordination, and educational challenges among healthcare professionals and patients. These include enhanced communication protocols, explicitly focusing on integrating the Electronic Health Records System (EHR), and comprehensive training programs for healthcare professionals.

Enhanced Communication Protocols: Establishing standardized communication channels between healthcare providers to communicate important information about patients’ histories and current treatment is essential to address communication gaps and improve coordination (Oliveros et al., 2019). Moreover, this strategy focuses on integrating the EHR system for healthcare providers to document management plans accurately. These plans and comprehensive patient records are accessible to the interdisciplinary team involved in patient care. This approach enhances collaboration and prevents provider communication errors (Vos et al., 2020). Implementing standardized communication protocols between surgeons and nursing staff is beneficial in addressing inadequate pain management as it helps the seamless transmission of postoperative pain management plans and improves collaboration among healthcare providers.

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Comprehensive Training Programs: Developing and conducting training programs for nurses on effective pain evaluation that covers essential topics such as assessment techniques, use of pain medications and their side effects, and information on non-pharmacological strategies will enhance their abilities to provide patient-centered pain management and care (Evans, 2021). Including simulation exercises within the training programs enhances nurses’ ability to assess and manage pain accurately in various scenarios, preparing them for diverse patient needs. This training is essential to foster a culture of regular pain assessments, addressing patients’ discomfort before it results in complications. Thus, it addresses the quality and safety issues of inadequate pain management in healthcare settings.

Safety Improvement Plan

Based on these evidence-based best practices, a safety improvement plan is instrumented for AdventHealth, Winter Park. This safety improvement plan is strategized on enhanced communication protocols with EHR Implementation and comprehensive training programs. The plan aims to address the scenario’s root causes – poor communication and collaboration and insufficient nurses’ experiences and education related to pain evaluation methods. Ultimately, the plan addresses inadequate pain management in the healthcare organization and improves healthcare practices to bring positive patient outcomes.

Implementing enhanced communication protocols and optimizing the utilization of EHR systems are vital to streamlining communication among healthcare providers, enhancing access to patient information, improving care plans, and generating better patient outcomes (Margam, 2023). The hospital will take various actions and processes under this strategy. Initially, the organization will establish a standardized communication software/portal within the EHR system to promote transparent and secure information sharing between surgical teams and nursing staff in the postoperative unit. This platform will include specific templates for postoperative orders, ensuring that pain management instructions are accurately conveyed.

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Additionally, the organization will provide ongoing support to healthcare providers for professional development regarding technological updates and proper utilization. The organization will also impose a policy for safe communication to maintain data security under the national policy of the Health Insurance Portability and Accountability Act (HIPAA), which emphasizes the importance of preserving patient privacy and confidentiality. The goal is to reduce communication gaps, increase collaboration, enhance the clarity of postoperative management plans, and reorganize information exchange among healthcare teams (Vos et al., 2020). The estimated timeline for development and implementation is six to eight months, which includes the initial phase of evaluating existing technological infrastructure and procuring necessary resources for smooth execution. The development of standardized templates and communication protocols will follow this. Training sessions for healthcare providers will be scheduled over the subsequent months.

Another approach to this safety improvement plan is to address the root cause of incomplete and inappropriate pain assessments due to the nurse’s lack of experience and education through a comprehensive training program for nursing staff (Samarkandi, 2021). The actions and processes required for this approach include the development of educational modules comprising evidence-based pain assessment techniques, effective communication skills, and information on non-pharmacological interventions. Collaborating with simulation experts, the healthcare facility must arrange simulation sessions for healthcare providers to deliver practical experience in assessing and managing various pain situations (Kurz et al., 2021).

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

AdventHealth should establish a policy mandating regular comprehensive training programs for nursing staff, ensuring maximum participation from nursing staff across the departments. The goal is to enhance nursing staff competencies in pain management, ensuring accurate and complete assessments and timely interventions. The timeline for development and implementation is approximately four to six months, involving an initial phase of curriculum development. Training sessions will be scheduled over an extensive period of two months to avoid disruptions in patient care. The plan will be followed by ongoing education and continuous monitoring of improved healthcare practices.

Organizational Resources

Our organization, AdventHealth, has several existing resources that can be leveraged to enhance the safety improvement plan addressing inadequate pain management. Because of its significance and potential impact, the hospital’s electronic information management system, the EHR, is the top resource on the priority list. This system is helpful as it provides a foundation for augmenting communication through integrated portals and protocols. The safety improvement plan necessitates leveraging the capabilities of the EHR system, such as developing a separate portal for surgical teams and nurses in postoperative areas to streamline their communication. Moreover, there is a significant need to enhance security measures within the system to adhere to the HIPAA and organizational policy of maintaining patients’ privacy.

The second vital resource is in-house training departments such as training rooms and simulation labs. These places can be leveraged for training sessions by utilizing multimedia for presentation and simulators for practicing training scenarios. These places allow nurses to learn and apply essential concepts in real-world settings. Experienced educators within the organization and training infrastructure are third on the priority list. They can contribute to developing and delivering evidence-based training modules, ensuring the organization’s policies, protocols, and standards are included in the education curriculum.

However, the plan necessitates the procurement of additional resources. Investments in technology are the top priority for optimizing the EHR system for enhanced communication functionalities. This includes software upgrades and the employment of robust security measures within the existing EHR system. Furthermore, for comprehensive training programs, additional resources may be required to develop high-quality educational materials, such as simulation equipment, training materials and logistics, and recruitment of external experts to deliver specialized training sessions.

Conclusion

This analysis discusses a patient safety issue at AdventHealth, focusing on inadequate postoperative pain management. The root-cause analysis identified communication, collaboration, and educational challenges among healthcare providers as factors impeding adequate pain management protocols within the organization. Thus, evidence-based best practices involve enhanced communication protocols, EHR optimization, and comprehensive training programs. Through a safety improvement plan, we direct the organizational stakeholders to bring significant changes within the healthcare setting and improve patient outcomes.

The successful implementation of this safety improvement plan relies on leveraging existing resources such as the hospital’s EHR system, training infrastructure, and healthcare educators prioritized accordingly. However, supplementary resources may be needed for technological upgrades and comprehensive training. Overall, the root-cause analysis and safety improvement plan aims to improve communication, enhance nursing staff competencies, address patient safety, and improve the quality of care related to inadequate pain management in healthcare settings.

References

Atthayasai, J., Chatchumni, M., Eriksson, H., & Mazaheri, M. (2023). Surgical nurses’ perceptions of strategies to enhance pain management proficiency: A qualitative study. Nursing Reports, 13(2), 923–933. https://doi.org/10.3390/nursrep13020081

Cao, L., & Hull, S. Z. (2021). Effectiveness of educating health care professionals in managing chronic pain patients through a supervised student inter-professional pain clinic. Medical Science Educator, 31(2), 479–488. https://doi.org/10.1007/s40670-020-01189-4

Evans, K. (2021). Staff education to improve pain management in skilled nursing patients. Doctoral dissertation, Walden University. https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=12062&context=dissertations

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Hämäläinen, J., Kvist, T., & Kankkunen, P. (2022). Acute pain assessment inadequacy in the emergency department: Patients’ perspective. Journal of Patient Experience, 9, 237437352110496. https://doi.org/10.1177/23743735211049677

Kurz, S., Lohse, J., Buggenhagen, H., Schmidtmann, I., Laufenberg-Feldmann, R., & Engelhard, K. (2021). Improving competence and safety in pain medicine: A practical clinical teaching strategy for students combining simulation and bedside teaching. BMC Medical Education, 21(1), 133. https://doi.org/10.1186/s12909-021-02554-6

Margam, R. (2023). The importance of ehr in revolutionizing healthcare delivery and financial success. International Journal of Computer Trends and Technology, 71(7), 52–55. https://doi.org/10.14445/22312803/IJCTT-V71I7P108

Oliveros, E., Brailovsky, Y., & Shah, K. S. (2019). Communication skills. JACC Case Reports, 1(3), 446–449. https://doi.org/10.1016/j.jaccas.2019.09.003

Samarkandi, O. A. (2021). The factors affecting nurses’ assessments toward pain management in Saudi Arabia. Saudi Journal of Anaesthesia, 15(2), 165–173. https://doi.org/10.4103/sja.sja_2_21