Root-Cause Analysis and Safety Improvement Plan

Healthcare-associated infections (HAIs) remain a major problem affecting healthcare delivery facilities, resulting in lengthened hospital stays, higher costs, and negative patient outcomes. Such infections are usually contracted due to negligence of infection control measures, insufficient environmental cleanliness and wrong usage of medical instruments. This paper assesses the root causes of HAIs, including HAI facts and causes and offers an improvement plan for safety. Utilizing literature-based interventions and organizational assets, this plan targets the reduction of HAIs, improvement of patient safety and the quality of care: Root-Cause Analysis and Safety Improvement Plan.

Analysis of the Root Cause

Healthcare-associated infections significantly contribute to infection control protocols, inadequate hand hygiene, and inappropriate sterilization of invasive devices, as noted by et al. (2022). The noted failures give rise to catheter-associated urinary tract infections, now more commonly called CAUTIs, and ventilator-associated pneumonia, VAP. The infection control team first highlighted the problem during routine audits, during which it was identified that there were repeated trends in non-adherence to hygiene protocols and inappropriate handling of equipment. More dramatically, these vulnerable populations—such as immunocompromised patients and the elderly—are affected by HAIs, often leading to prolonged hospital stays, deteriorated health outcomes, and increased expenditures in healthcare.

The RCA identified the root causes that contributed to HAIs. It noted process failures such as inadequate adherence to hand hygiene and inappropriate cleaning protocols. Human elements that further exacerbated the situation included inadequate training and awareness among healthcare staff and understaffing during critical shifts.

Some environmental factors included poor cleaning of high-touch surfaces and poor ventilation in healthcare settings. Further, problems with equipment, such as insufficient sterilization of invasive equipment, became another cause of the infections. In aggregate, it demonstrates the changes that should be made at the system level in addressing HAIs.

Application of Evidence-Based Strategies

Several approaches can be followed as we try to implement solutions to tackle HAIs. Adherence to the WHO’s “Five Moments for Hand Hygiene” concept has been identified as a best practice, as noted by Chakma et al. (2024). This framework centres around several points in patient care when hand washing is critical. The placement of alcohol-based hand sanitizers at strategic points and compliance monitoring have minimized infections.

Sun et al. (2023) posited that innovative systems of environmental decontamination, including UV and hydrogen peroxide, can potentially eradicate pathogens in special units like ICU. These technologies promote improved cleanliness of healthcare facilities and decrease the transfer of infection. First, it is crucial to implement antimicrobial stewardship programs to manage antibiotic consumption and avoid the dissemination of MDOs. Some programs include making people aware of when and when not to use antibiotics and adherence to prescription measures.

Second in importance should be staff education and training. This measure enables caregivers and healthcare institutions to increase their knowledge and compliance with infection prevention measures since simulation-based training of complex interventions increases confidence in actual practice (Zhang et al., 2024). This should be accompanied by usually arranged and periodic awareness creation sessions that ensure staff is up-to-date on the present latest guidelines on the principles of infection control. These interventions target HAIs by directly intervening with hygiene, environment and cleaning, antibiotic stewardship, and staff knowledge.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The proposed safety improvement plan is structured to offer a comprehensive identification of root causes. This plan first looks to strengthen hand hygiene practices by installing additional handwashing stations with alcohol-based sanitizers around the facility and conducting periodic audits to prove compliance. Several educational materials will be visible through posters and digital displays to further reinforce good hand hygiene behaviour among staff and visitors.

Notably, environmental cleaning practices would improve through UV disinfection robots and hydrogen peroxide vapour systems to serve high-risk areas. In addition to using such technologies, an integrated cleaning program would ensure uniform frequency for high-touch surfaces to realize the goal of effective sanitation by Sun et al. (2023). The antimicrobial stewardship program would strive on a multidisciplinary committee on antibiotic stewardship. It shall establish guidelines regarding antibiotic prescriptions, monitor their observance, and continuously educate health workers about the risks of antibiotic resistance.

The core of the improvement plan will be staff education and training. Simulation-based training will reinforce infection prevention protocols and proper handling of invasive devices. All healthcare staff will undergo refresher courses on using and maintaining medical equipment, such as catheters and ventilators. These trainings will equip the staff with the knowledge and skills to prevent and control HAIs effectively.

Subsequently, the main objective of the improvement plan is to decrease the rates of HAI by 25% within six months. Other goals are to achieve 90% compliance with hand hygiene in three months and complete adherence to new environmental cleaning protocols in six months. The plan will be implemented in three phases.

Phase 1, for the first three months, will include needs assessment, equipment procurement, and staff training. Phase 2, between four to six months, will be the implementation of hand hygiene and environmental cleaning while monitoring the stewardship program of antimicrobials. Phase 3, from months seven to twelve, includes analysis of infection rates and revising the improvement plan based on the outcomes.

Existing Organizational Resources

            The proposed safety improvement plan will be executed using the available resources within the organization. Infection control specialists, clinical educators, and nursing staff will significantly execute the plan. They will be responsible for training, monitoring compliance, and evaluating outcomes.

The hand hygiene stations and disinfection equipment already available in the facility will be utilized to the fullest to minimize additional costs. Infection trends and compliance with new practices will be monitored using the EHRs (Kataria & Ravindran, 2020).

It will also buy other resources, like UV disinfection robots and advanced cleaning supplies, which can enhance infection prevention. The estimated budget allocations also cover the cost required for employees’ training programs and any hiring needed. These partnerships may result in more financing or advanced technologies to support the plan.

Conclusion

Healthcare-associated infections are a major problem with complex solutions that can only be addressed through a systems approach to address patient safety and the quality of care they receive. This root-cause analysis determined the various process failings, human errors, and environmental inadequacies that led to HAIs. The recommended safety improvement plan includes elements of the Best Practice Safety model, including hand hygiene alteration, advanced cleaning methods, antimicrobial stewardship and staff education.

Policies have estimated that by employing what is already available in healthcare organizations and encouraging safety, HAIs are lowered, patient conditions are aided, and the reputation of the health facilities is boosted. Continuous assessment and modification of the plan will make the course persistent and useful.

References

Alamer, A., Alharbi, F., Aldhilan, A., Almushayti, Z., Alghofaily, K., Elbehiry, A., & Abalkhail, A. (2022). Healthcare-Associated Infections (HAIs): Challenges and Measures Taken by the Radiology Department to Control Infection Transmission. Vaccines, 10(12), 2060. https://doi.org/10.3390/vaccines10122060

Chakma, S. K., Saheen Hossen, Tareq Mahmud Rakib, Hoque, S., Islam, R., Biswas, T., Islam, Z., & M Munirul Islam. (2024). Effectiveness of a hand hygiene training intervention in improving knowledge and compliance rate among healthcare workers in a respiratory disease hospital. Heliyon, 10(5), e27286–e27286. https://doi.org/10.1016/j.heliyon.2024.e27286

Kataria, S., & Ravindran, V. (2020). Electronic health records: a critical appraisal of strengths and limitations. Journal of the Royal College of Physicians of Edinburgh, 50(3), 262–268. https://doi.org/10.4997/jrcpe.2020.309

Sun, Y., Wu, Q., Liu, J., & Wang, Q. (2023). Effectiveness of ultraviolet-C disinfection systems for reduction of multi-drug resistant organism infections in healthcare settings: A systematic review and meta-analysis. Epidemiology and Infection, 151(2). https://doi.org/10.1017/s0950268823001371

Zhang, M., Wu, S., Ibrahim, M. I., Noor, S. S. M., & Mohammad, W. M. Z. W. (2024). Significance of Ongoing Training and Professional Development in Optimizing Healthcare-associated Infection Prevention and Control. Journal of Medical Signals & Sensors, 14(5), 14. https://doi.org/10.4103/jmss.jmss_37_23

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Assessment 2: Root-Cause Analysis and Safety Improvement Plan
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 choice as well as a safety improvement plan.

Introduction
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures.

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 professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

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 improvements.

Scenario
For this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan.

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 (ATTACHED) 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 (Order 59145).

Root-Cause Analysis and Safety Improvement Plan