Learning Objectives

Learning Objectives

2 Steps Day 3 And Day 4
When patient safety is compromised, it is critical to get to the root of the issue in order to determine how to ensure patient safety and avoid risks in the future. Nurses can use analytical techniques to determine root causes related to various types of errors. Medication error is a typical error that can be subject to process improvement in general, and root cause analysis in particular. This process came out of NASA after the Space Shuttle Columbia disaster and has been adopted by the health care industry. This week, you analyze a case related to medication error, and you examine how root cause analysis is applied to prevent future error and formulate process improvement plans.
Learning Objectives
Students will:

• Analyze the composition of a root cause analysis team      in relation to effective practice
• Critique the effectiveness of the performance      improvement charts in identifying contributing factors
• Apply findings from a root cause analysis to prevent      future errors
• Apply a quality improvement process to an improvement      plan

 
Learning Resources 
Required Readings
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.
· Chapter 4, “Evaluating Performance” (pp. 73–110)
· Chapter 5, “Continuous Improvement” (pp. 111–130)
· Chapter 6, “Performance Improvement Tools” (pp. 131–162)
Note: Although these chapters are previously assigned readings, please review them in preparation for this week’s material.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby.
· Chapter 17, “Leading Change” (pp. 305–320)
· Chapter 23, “Conflict: The Cutting Edge of Change” (pp. 431–447)
Required Media
Laureate Education (Producer). (2016a). Root cause analysis at Downtown Medical [Interactive file]. Baltimore, MD: Author.
Laureate Education (Producer). (2016b). RCA dramatization 1 [Video file]. Baltimore, MD: Author.
Note: The approximate length of this media piece is 4 minutes.
Case scenario involving medication error including pharmacy, physician, and nurse—interdepartmental collaboration.
Interactive media—students select options that generate chart based on choices
(Voiceover reads the document aloud—include a downloadable pdf).
 
Discussion: Root Cause Analysis
Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.
By Day 3
Post each of the following:

• Analyze the composition of the RCA team. Explain what      knowledge they can contribute to the RCA.
• Describe the collaboration in the case study that led      to effective problem solving. Identify the evidence you observe in the      scenario that demonstrates effective collaboration and the avoidance of      blaming.
• Explain the team’s process in testing for and      eliminating root causes that were not contributing.
• Select one of the performance improvement charts      presented in the scenario and critique its effectiveness by explaining how      it contributes to identifying the root cause and determining a solution to      prevent repeat medication errors.
• Identify the contributing factors, and discuss how to      prevent this kind of error from occurring in the future.

Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level (see checklist)
Notes Initial Post: This should be a 3-paragraph (at least 350 words) response. Be sure to use evidence from the readings and include in-text citations.
 
Practice Experience: Stakeholder Analysis
The next step in the process is to begin identifying the challenges and impediments to implementing a quality improvement plan. In the analysis consider the individuals affected by the change as well as the cost of implementing the quality improvement plan.
By Day 4
Post a description of some of the proposed action steps for implementing improved practice, and explain where potential challenges might compromise your proposed improvement project. Describe what resources are needed for your solution, and explain whether or not those resources are cost-effective. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project, and share this information with your group.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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