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

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Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

This root-cause analysis (RCA) explores the issue of inadequate pain management at Mercy General Hospital, focusing on a specific sentinel event involving Mr. Thompson, a 52-year-old patient with a severe back injury. The RCA will examine factors contributing to this quality and safety issue, assess the impact on patient outcomes, and propose a comprehensive safety improvement plan to enhance pain management practices, ensuring better patient care and cost efficiency.

Analysis of the Root Cause

Description of the Event

The event focuses on inadequate pain management experienced by Mr. Thompson, a 52-year-old construction worker admitted to Mercy General Hospital following a severe back injury. His initial pain assessment was insufficient, as he was treated solely on his verbal reports, and his non-verbal gestures of distress were ignored. Moreover, due to significant communication barriers between the nursing staff and the pain management team, there was a delayed administration of primary analgesics like acetaminophen. Furthermore, the healthcare providers hesitated to prescribe more substantial pain relief due to concerns about opioid addiction despite Mr. Thompson’s persistent pain. As a result, his recovery was significantly deferred, leading to lengthier hospital stays, augmented stress, and a reduced quality of life. 

Root-Cause Analysis 

Several factors contributed to this sentinel event. A comprehensive pain assessment should have been conducted, incorporating both verbal and non-verbal indicators. The failure to do so resulted in an incomplete understanding of Mr. Thompson’s pain level. According to the literature, a holistic and integrated approach to pain management can result in positive patient outcomes, where initial assessment stands out as a critical component, ensuring the interventions address complete patients’ needs (Dydyk & Grandhe, 2023). Another contributing aspect is a communication breakdown between healthcare teams that led to delayed medication administration, further exacerbating the issue.

Communication is vital in healthcare settings, where better patient outcomes are achieved with improved interdisciplinary communication, reducing care delays and enhancing patient satisfaction with care (Sheehan et al., 2021). Other factors include environmental contributors such as high patient loads and time constraints, which may have influenced the quality of pain assessments; resource limitations, including the unavailability of pain management specialists, also played a role; and human errors, such as the healthcare team’s reluctance to prescribe advanced pain relief driven by concerns over opioid addiction but failed to address the patient’s immediate needs. 

Evidenced-Based and Best Practice Strategies

Several best practices are established by scholarly studies, emphasizing the use of comprehensive pain assessment tools and enhanced communication systems. 

Comprehensive Pain Assessment Protocols

Implementing comprehensive pain assessment protocols involves using both subjective and objective measures to evaluate pain accurately (Dydyk & Grandhe, 2023). This includes regular utilization of validated pain assessment tools to ensure consistent and thorough evaluations, as well as reinforcing healthcare providers to focus on non-verbal pain indicators. In a study, it was recognized that 88% of nurses used validated pain assessment scales for critically ill patients, resulting in accurate pain evaluation, timely intervention, and positive patient outcomes (Saleh, 2023). Thus, by accurately assessing pain, healthcare providers can prevent under-treatment and ensure adequate pain management. 

Enhanced Communication Systems

Improving communication systems among healthcare teams can address delays and miscommunications in pain management. Li et al. (2022) justify the implementation of electronic health records (EHR) to keep interprofessional teams on one platform through interoperability of the system to ensure seamless information exchange. Verbal and written orders, especially for pain management, should be avoided to guarantee timely administration of drugs. Moreover, regular interdisciplinary meetings and huddles can also facilitate better communication and coordination of care. These strategies ensure that pain management information is promptly relayed and acted upon, reducing the risk of oversight and delays. 

Improvement Plan with Evidence-Based and Best-Practice Strategies

To address the issue of inadequate pain management, Mercy General Hospital will implement a comprehensive safety improvement plan focused on enhancing pain assessment protocols and communication systems.

Proposed Actions and New Processes

• Comprehensive Pain Assessment Protocols: Develop and standardize pain assessment protocols using validated pain assessment scales. This ensures a holistic measurement of patients’ pain, including subjective and objective data. This plan includes training for all nursing staff on using validated pain assessment tools such as Numeric Pain Scale (NPS) and recognizing non-verbal pain indicators, ensuring holistic evaluation and development of personalized pain alleviation plans (Deldar et al., 2020). 

1. Enhanced Communication Systems: Implement an EHR system with integrated pain management alerts to ensure real-time updates on patient pain status and treatment plans. This system will include alerts for timely pain reassessments and alerts for opioid addiction, thus allowing healthcare providers to administer advanced analgesics, including narcotics (Vock et al., 2022).

Furthermore, for professional development, the Mercy General Hospital should conduct regular workshops and training sessions for healthcare providers on pain management best practices and communication strategies. This includes training on the appropriate use of opioid and non-opioid pain relief options and fostering collaborative care teams. Research supports that ongoing education improves adherence to best practices and enhances care quality (Deldar et al., 2020). The ultimate goals and desired outcomes of this safety improvement plan are better pain control, reduced patient suffering, and faster recovery. Moreover, through enhanced communication systems, the plan aims to deliver coordinated care to minimize delays and errors in pain management, improving overall patient safety. Finally, through efficient pain management, we desire to reduce the length of hospital stays, decrease healthcare costs, and enhance quality of life (Saleh, 2023). 

Plan Timeline

Overall, the plan is distributed over 12 months as follows: 

• Months 1 and 2: Development of pain assessment protocols and procurement/upgrade of EHR systems to integrate pain management alerts. 
• Months 3 and 4: Conduct staff training on standardized pain assessment tools, implement the EHR system, and train staff on using technology. This phase also includes addressing initial barriers to smooth implementation.
• Months 5 and 6: Roll out comprehensive pain assessment protocols and ongoing professional development sessions.
• Months 7 to 12: Ongoing monitoring of safety improvement plan implementation, gathering feedback, and making necessary adjustments to the plan, ensuring continuous enhancements according to the evidence-based best practices and organizational needs. 

Existing Organizational Resources 

To enhance the safety improvement plan at Mercy General Hospital, several existing organizational resources can be leveraged. 

1. Clinical staff and pain management experts are crucial for developing and implementing comprehensive pain assessment protocols and training programs. Pain management specialists are exceptionally trained and know the effective strategies and best practices (Santosa, 2020), which will help in the smooth implementation of a safety improvement plan and ensure adherence to these best practices. 
2. Moreover, the hospital’s existing IT infrastructure can be utilized to integrate new pain management alerts into the EHR system. IT personnel can assist in integrating this system, ensuring that patients’ data is adequately secured. Information technology (IT) must handle healthcare data by robust security measures and address ongoing technological concerns (Javaid et al., 2023). 
3. Finally, training material and resources for professional development and continuing education programs will be used. These include multimedia training rooms, trainers and educators, and paper-based and online educational resources. 

However, several resources must be obtained from outside the hospital. Advanced pain management tools, such as validated pain assessment tools and updated EHR modules, may need to be acquired to support the new protocols. Additionally, the organization may need to engage with external experts for specialized training on pain management best practices. By effectively leveraging these existing resources and acquiring the necessary tools and expertise, Mercy General Hospital can successfully implement and sustain the safety improvement plan.

Conclusion 

In conclusion, this assessment discussed the root-cause factors of a sentinel event, including Mr. Thompson’s experience at Mercy General Hospital. The RCA presented factors like communication breakdowns and lack of adequate pain assessment protocols that led to adverse patient outcomes. Thus, using evidence-based practices, such as comprehensive pain assessment protocols and enhancement communication systems, a safety improvement plan is established for the organization to address inadequate pain management crucial for enhancing patient care and safety.

By implementing these best practices and leveraging existing resources, the hospital can significantly improve pain management practices. The proposed plan aims to ensure accurate pain assessments, timely interventions, and better coordination among healthcare teams, ultimately reducing patient suffering, hospital stays, and healthcare costs. The successful execution of this plan will lead to improved patient outcomes and a safer healthcare environment.

References

Deldar, K., Froutan, R., Sedaghat, A., & Mazlom, S. R. (2020). Continuing nursing education: Use of observational pain assessment tool for diagnosis and management of pain in critically ill patients following training through a social networking app versus lectures. BMC Medical Education, 20(1). https://doi.org/10.1186/s12909-020-02159-5 

Dydyk, A. M., & Grandhe, S. (2023). Pain assessment. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556098/

Javaid, D. M., Haleem, Prof. A., Singh, D. R. P., & Suman, D. R. (2023). Towards insighting cybersecurity for healthcare domains: A comprehensive review of recent practices and trends. Cyber Security and Applications, 1(100016), 100016. https://doi.org/10.1016/j.csa.2023.100016 

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

Li, E., Clarke, J., Ashrafian, H., Darzi, A., & Neves, A. L. (2022). The impact of electronic health record interoperability on safety and quality of care in high-income countries: Systematic review. Journal of Medical Internet Research, 24(9). https://doi.org/10.2196/38144

Saleh, A. M. (2023). Nurses’ assessment and management practices of pain among intensive care patients in King Khalid Hospital, Kharj, Riyadh. Heliyon, 9(9), e19986–e19986. https://doi.org/10.1016/j.heliyon.2023.e19986

Santosa, A. (2020). A pain management specialist. MEDISAINS, 17(3), 50. https://doi.org/10.30595/medisains.v17i3.6396 

Sheehan, J., Laver, K., Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. A. (2021). Methods and effectiveness of communication between hospital allied health and primary care practitioners: A systematic narrative review. Journal of Multidisciplinary Healthcare, 14(14), 493–511. https://doi.org/10.2147/JMDH.S295549

Vock, D. M., Neprash, H. T., Hanson, A. V., Elert, B. A., Satin, D. J., Rothman, A. J., Short, S., Karaca-Mandic, P., Markowitz, R., Melton, G. B., & Golberstein, E. (2022). Prescribing interventions for chronic pain using the electronic health record (PRINCE): Study protocol. Contemporary Clinical Trials, 121, 106905. https://doi.org/10.1016/j.cct.2022.106905 

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