Assessment 2: Root-Cause Analysis and Safety Improvement Plan
Name
Capella University
NURS4020: Improving Quality of Care and Patient Safety
Instructor Name
March, 2024
Root-Cause Analysis and Safety Improvement Plan
In a healthcare setting, inadequate patient education significantly impacts patient safety, leading to misuse of medications, poor treatment adherence, and increased hospital readmissions. It compromises patient empowerment and autonomy as they struggle to make informed decisions about their health. This education gap escalates healthcare costs, lowers patient satisfaction, and poses legal risks due to inadequate informed consent. Additionally, it neglects the holistic care aspect, ignoring the emotional and psychological needs of patients. Addressing this issue through comprehensive educational strategies is essential for improving patient outcomes and the overall effectiveness of healthcare systems (Jindal et al., 2020).
Analysis of the Root Cause
The root cause analysis of inadequate patient education in healthcare revealed that this issue was detected by healthcare providers who noticed patterns of patient complications. The primary victims were the patients who suffered from adverse health outcomes due to insufficient knowledge about their conditions and treatments. Several key findings from recent studies can inform the root cause analysis of the sentinel event. Research shows that patient education, especially for chronic diseases like cardiovascular disease, is not just about disseminating information; it’s about engaging patients in a manner that respects their need to understand why they should learn something and how it will benefit them. This involves tailoring the educational material to individual needs and backgrounds, emphasizing the usefulness and essentiality of education as part of treatment, and involving family members in the learning process for better reinforcement and understanding (Khamaiseh & Altarawneh, 2024).
Furthermore, a study examining the impact of health literacy on patient outcomes revealed a strong correlation between low health literacy and adverse health outcomes. Inadequate health literacy, particularly among older and economically disadvantaged patients, increases the likelihood of emergency department revisits and hospital readmissions (BioMed Central). This indicates that a one-size-fits-all approach to patient education is insufficient and potentially harmful, emphasizing the need for personalized, accessible educational strategies.
Additionally, the involvement of healthcare staff in patient education is crucial. Staff competency and comfort in discussing health-related topics significantly influence the effectiveness of patient education. However, a lack of structured training and time constraints are notable barriers. Research also suggests that educational interventions in urgent and emergency care settings are both possible and beneficial. Still, there’s a need for a more systematic approach and further research to identify effective methods specifically tailored for these settings (Oh et al., 2023). A holistic approach that encompasses patient education, engagement, and empowerment is essential. This approach should be integrated early in life and focus on various aspects of health, including diet, physical activity, and oral health. Such an approach is particularly important for patients with chronic conditions who require ongoing support and guidance to manage their health effectively. The root causes of inadequate patient education in healthcare include:
- There is a need for personalized and tailored educational approaches.
- Need for more health literacy among patients.
- Barriers faced by healthcare staff in delivering effective patient education.
Addressing these root causes requires a multifaceted approach that involves personalized patient education, improving health literacy, and equipping healthcare professionals with the necessary training and resources to engage in effective health education and promotion (Agarwal et al., 2020).
Application of Evidence-Based Strategies
Evidence-based and best-practice strategies have been identified through literature to address the safety issue of inadequate patient education in healthcare. One effective approach involves interactive teaching strategies. Group work has been highlighted for its role in establishing research utilization and improving critical thinking skills. Another strategy is the integration of interactive and clinically integrated teaching strategies. These include collaboration with healthcare personnel in clinical practice and assignments based on this collaboration. Teaching the principles of EBP is crucial, focusing on steps like research utilization and practical application in a clinical setting (Degu et al., 2022).
Furthermore, an information literacy training program for nurses significantly improved their use of various information resources, particularly electronic resources, and their information searching skills and knowledge about search operators. This training involved hands-on and online exercises, illustrating the importance of practical, interactive learning in improving EBP readiness. Key strategies for effectively addressing the issue of inadequate patient education are employing interactive teaching methods, focusing on clinically integrated EBP teaching, and conducting comprehensive information literacy training programs for healthcare providers. These methods not only enhance the understanding and skills of healthcare providers but also contribute to the improved delivery of patient education (Cutilli, 2020).
Improvement Plan with Evidence-Based and Best-Practice Strategies
A feasible, evidence-based safety improvement plan can be developed to address inadequate patient education in healthcare. The plan should focus on integrating interactive teaching strategies and clinically integrated teaching methods, such as problem-based learning, flipped classrooms, and group work, enhancing understanding of evidence-based practices among healthcare providers. These methods have been highlighted as effective in the context of nursing education and can be adapted for broader healthcare settings.
These actions aim to improve the quality of patient education, ensure a better understanding of their health conditions, and ultimately reduce adverse health outcomes due to mismanagement. The timeline for developing and implementing this plan should be phased, beginning with the training of healthcare providers, followed by integrating these methods into patient education processes. Regular assessment and feedback loops should be established to ensure continuous improvement and adaptation of the strategies to the specific needs of the healthcare setting. This plan aligns with the principles of quality improvement in healthcare, emphasizing the need for adaptation to context and iterative testing to ensure the effectiveness of the interventions (Pitsillidou et al., 2021).
Leveraging existing organizational resources is essential to improve patient safety in healthcare settings. Key resources include personnel with specific roles in implementation, such as hospital leadership, implementation champions (e.g., physicians and nurses), and frontline implementers (mainly physicians). These individuals can provide crucial support for introducing and maintaining safety initiatives, as they bring varied perspectives and expertise vital for successful implementation. However, it’s important to recognize the challenges related to limited resources, such as the need for protected time for project work, staff support for data collection or analytics, and adequate training for these roles. The lack of these resources can hinder the uptake of new initiatives and impact their sustainability (Martin-Delgado et al., 2020).
A multifaceted communication approach combining passive and active strategies enhances the impact of safety improvement plans. This approach helps in effectively disseminating information about new practices and ensuring wider adoption. Furthermore, recognizing efforts and successes in implementing safety initiatives is crucial. Still, it should be complemented with sufficient financial investment to ensure these initiatives’ long-term sustainability and scalability. Successfully implementing safety improvement plans relies heavily on well-coordinated efforts involving various organizational roles and resources. Addressing any gaps in resources and ensuring continuous support, both in terms of recognition and financial investment, for ongoing and future safety initiatives is also essential (Delavar et al., 2020).
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan Conclusion:
In conclusion, addressing inadequate patient education in healthcare requires a multifaceted and evidence-based approach. Integrating interactive teaching methods and information literacy training for healthcare providers enhances understanding and implementation of evidence-based practices. Leveraging existing organizational resources, such as skilled personnel and effective communication strategies, is crucial for the success of safety improvement plans. Challenges such as resource limitations and the need for financial investment in long-term sustainability must be addressed. By combining these strategies, healthcare organizations can significantly improve patient education and safety, leading to better health outcomes and more efficient healthcare delivery (Edward et al., 2021).
NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan References:
Agarwal, N., Funahashi, R., Taylor, T., Jorge, A., Feroze, R., Zhou, J., Hansberry, D. R., Gross, B. A., Jankowitz, B. T., & Friedlander, R. M. (2020). Patient education and engagement through multimedia: A prospective pilot study on health literacy in patients with cerebral aneurysms. World Neurosurgery, 138, e819–e826. https://doi.org/10.1016/j.wneu.2020.03.099
Cutilli C. C. (2020). Excellence in patient education: Evidence-based education that “sticks” and improves patient outcomes. The Nursing Clinics of North America, 55(2), 267–282. https://doi.org/10.1016/j.cnur.2020.02.007
Degu, A. B., Yilma, T. M., Beshir, M. A., & Inthiran, A. (2022). Evidence-based practice and its associated factors among point-of-care nurses working at the teaching and specialized hospitals of Northwest Ethiopia: A concurrent study. PloS One, 17(5), e0267347. https://doi.org/10.1371/journal.pone.0267347
Delavar, F., Pashaeypoor, S., & Negarandeh, R. (2020). The effects of self-management education tailored to health literacy on medication adherence and blood pressure control among elderly people with primary hypertension: A randomized controlled trial. Patient Education and Counseling, 103(2), 336–342.
Edward, A., Campbell, B., Manase, F., & Appel, L. J. (2021). Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania. BMC Health Services Research, 21(1), 834. https://doi.org/10.1186/s12913-021-06858-7
Jindal, H. A., Saraswathy, M. V., Gupta, A., & Thakur, J. S. (2020). Improvement of patient satisfaction by root cause analysis in health care services for urban slum community in North India. Journal of Family Medicine and Primary Care, 9(4), 2125–2128. https://doi.org/10.4103/jfmpc.jfmpc_915_19
Khamaiseh, A. M., & Altarawneh, F. Z. (2024). Factors and barriers influencing practice of health education among nursing students in Jordan. Journal of Education and Health Promotion, 12, 441.
Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of root cause analysis Translates into improved patient safety: A systematic review. Medical principles and practice: International journal of the Kuwait University, Health Science Centre, 29(6), 524–531.
Oh, E. G., Lee, J. Y., Lee, H. J., & Oh, S. (2023). Effects of discharge education using teach-back methods in patients with heart failure: A randomized controlled trial. International Journal of Nursing Studies, 140, 104453.
Pitsillidou, M., Roupa, Z., Farmakas, A., & Noula, M. (2021). Factors affecting the application and implementation of evidence-based practice in nursing: Journal of the Society for Medical Informatics of Bosnia & Herzegovina, 29(4), 281–287. https://doi.org/10.5455/aim.2021.29.281-287
