Root-Cause Analysis and Safety Improvement Plan
The Joint Commission (2019) stated that the lack of effective patient education remains a main cause of adverse events and high mortality rates in healthcare organizations. This analysis focuses on a specific sentinel event, including inadequate discharge education leading to preventable hospital readmission. The root cause of this safety issue will be discussed in the subsequent sections, together with evidence-based intervention strategies. The paper will also outline a comprehensive safety improvement intervention plan, including components and logistics of implementation and the organizational resources that must be available for the intervention: Root-Cause Analysis and Safety Improvement Plan.
Analysis of the Root Cause
A sentinel event that happened in the Metropolitan General Hospital cardiac unit involved an adult patient aged 65 years who had a recent history of myocardial infarction and an undesirable event. Seventy-two hours after discharge, the patient returned to the emergency department complaining of chest pain and shortness of breath. The reason for the adverse event established in this study was medication noncompliance and early warning sign failure of complications, which the patient suffered because of poor discharge education.
Notably, this particular event had more profound implications than the rather clinical outcomes the patient experienced. The health system faced problems like unnecessary readmission costs, and the patient experienced physical and emotional pain that could have been prevented. The occurrence prompted a profound exploration of defusing the discharge education process.
Some of the significant critical factors were identified through system-level analysis and categorized as the cause of this safety event. Discharge planning should have addressed medication management teaching, identification of signs that require a medical reevaluation, and the teach-back approach to validate patient understanding of the information provided to them and their families. It should also have assessed the family’s engagement in the discharge planning process and scheduled follow-up appointments (Soon et al., 2021). Nevertheless, many tier-level organizational deficiencies failed to incorporate these critical components properly.
The unit’s high output, which put massive time pressure during the discharge process, and the noise, which interfered with proper communication between the health care providers and the patient, were the only environmental issues that seemed to play a role in this failure of patient teaching. The absence of a separate area for patient enlightenment also urged an additional challenge to share crucial knowledge with the patient. Further, the lack of resources also played a crucial role in the event.
The unit also lacked patient education material in the language that the patient preferred, and translation services were few and far between during the patient’s discharge. Additionally, lacking a structured perforation, certain necessary information may fail to be included in the education process.
Human factors became the significant contributors to the event. The haste to discharge the patient as quickly as possible made staff hurriedly go through the procedure of discharge without asking about his level of health literacy. Documentation of education was incomplete, and it was, therefore, difficult to follow what information had been given out and understood.
Communication barriers represented another major determinant. Linguistic differences between professional staff and the patient caused certain obstacles to proper information flow; similarly, using complicated medical terms in conditions of discharge instructions added more complexity to the process of understanding by patients. The lack of family involvement in the education process eliminated an important support system that could have reinforced crucial care instructions.
Application of Evidence-Based Strategies
Recent studies provide good evidence to support strategies for addressing inadequate patient education. For instance, studies by (Yen and Leasure, 2019) have found that integrating the teach-back technique may enhance patients’ understanding while readmission rates decrease percent. The teach-back technique helps ensure patients are in a position to repeat and demonstrate an understanding of crucial care instructions.
Further support for the effectiveness of structured discharge education protocols came from additional research studies conducted by Mbanda et al. (2020). Their studies reportedly indicated that the use of visual aids, in addition to simplified language within discharge instructions, can be associated with a reduction in medication errors.
Moreover, critical information omission can be reduced due to standardized discharge education checklists. The literature consistently supports the fact that multimodal approaches have demonstrated increased retention of information by as high as 65%, provided through verbal, written, and visual means of instruction. Family involvement in education reduces the readmission rate by 25%, and follow-up calls within 48 hours post-discharge shows a 50% reduction in complications (Vernon et al., 2019).
Improvement Plan with Evidence-Based and Best-Practice Strategies
Based on the root causes identified and evidence-based strategies, a six-month comprehensive improvement plan was developed. The foundational elements will be developed and implemented over the first two months, including a standardized protocol for discharge education, a comprehensive checklist incorporating the teach-back method, simplified education materials in multiple languages, and quiet zones exclusively for patient education.
The following two months will be utilized for staff training activities regarding health provider training on the teach-back methodology, assessment of health literacy, cultural competency, and documentation requirements. This training phase is significant in uniformly implementing the new protocols efficiently.
Month three will begin the new process implementation through a pilot, including mechanisms for daily monitoring and feedback. Compliance and outcome metrics, routinely collected, will further enable the identification of areas needing adjustment or reinforcement.
Months ten and eleven will be utilized for evaluation and adjustment based on the readmission rates, patient satisfaction scores, staff feedback, and overall effectiveness of the protocols. The plan’s goals are concrete and measurable: a 30% readmission rate reduction, a 50% improvement in overall patient satisfaction scores, 80% compliance with the new education protocol, and a 40% reduction in medication complications. Monthly tracking will take place for reported outcomes to ensure progress toward objectives.
Existing Organizational Resources
The success of the improvement plan largely depends on how well resources within the current organization are utilized. Clinical nurse educators will provide staff training and subsequent education support. The quality improvement team will oversee the development and implementation of protocols. At the same time, any updates related to the documentation system will be handled through the information technology department.
The Department of Translation Services will support the development of multilingual education materials and ensure communication with non-English-speaking patients. The patient education materials department, staff development coordinators, unit-based clinical nurses, and the social work department will provide additional support.
Multiple resources would be needed to implement this improvement plan, including educational materials in several languages, equipment for dedicated education space, technologies that allow the virtual involvement of family members or friends, and updated documentation (Kuwabara et al., 2020). The resources would then be prioritized based on their likelihood of significantly improving patient outcomes and feasibility in implementation.
Conclusion
The root cause analysis of this sentinel event provides evidence that inadequate patient education represents a significant and correctable safety risk in healthcare. The most crucial root cause was the lack of a uniform, patient-centered approach to discharge education, leading to unnecessary readmission and complications. This will provide an overall approach to improving patient education and minimizing adverse events through evidence-based strategy implementation and judicious leveraging of resources within the organization. Accomplishing desired outcomes in this endeavor would presuppose continuous commitment of stakeholders and a regular assessment of results to effect continuous refinement of processes based on feedback and results.
References
Joint Commission International. (2019). Communicating Clearly and Effectively to Patients How to Overcome Common Communication Challenges in Health Care. https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-final_(1).pdf
Kuwabara, A., Su, S., & Krauss, J. (2020). Utilizing Digital Health Technologies for Patient Education in Lifestyle Medicine. American Journal of Lifestyle Medicine, 14(2), 137–142. https://doi.org/10.1177/1559827619892547
Mbanda, N., Dada, S., Bastable, K., Ingalill, G.-B., & Ralf W., S. (2020). A scoping review of visual aids in health education materials for persons with low literacy levels. Patient Education and Counseling, 104(5). https://doi.org/10.1016/j.pec.2020.11.034
Soon, H. C., Geppetti, P., Lupi, C., & Kho, B. P. (2021). Medication Safety (L. et al., Eds.). PubMed; Springer. https://www.ncbi.nlm.nih.gov/books/NBK585602/
Vernon, D., Brown, J. E., Griffiths, E., Nevill, A. M., & Pinkney, M. (2019). Reducing readmission rates through a discharge follow-up service. Future Healthcare Journal, 6(2), 114–117. https://doi.org/10.7861/futurehosp.6-2-114
Yen, P. H., & Leasure, A. R. (2019). Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes. Federal Practitioner, 36(6), 284–289. https://pmc.ncbi.nlm.nih.gov/articles/PMC6590951/
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Question 
Assessment 2 Root cause analysis
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 in a health care setting of your
Introduction
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety
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
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety
Professional Context
Nursing 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
Scenario
For this assessment, use the specific safety concern
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 safety quality issue presented in your Assessment Supplement PDF in Assessment 1. 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, 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 specific patient safety issue in an organization.
- Apply evidence-based and best-practice strategies to address the safety issue.
- Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
- Identify organizational resources that could be leveraged to improve your plan.
- 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 the quality issue you selected in Assessment 1.
Root-Cause Analysis and Safety Improvement Plan
- Assessment 2 Example [PDF] (Attached)
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 a specific patient safety issue.
- 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.
By successfully completing this assessment, you will demo
- Competency 1: Analyze the elements of a successful quality improvement initiative.
- Apply evidence-based and best-practice strategies to address the safety issue.
- Create a feasible, evidence-based safety
improvement plan to address a specific patient safety issue.
- Competency 2: Analyze factors that lead to patient safety risks.
- Analyze the root cause of a specific patient safety
issue in an organization.
- Analyze the root cause of a specific patient safety
- Competency 3: Identify organizational interventions to promote patient safety.
- Identify organizational resources that could be leveraged to improve your plan.
- Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
- Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
- Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Scoring Guide
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