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

Root Cause Analysis and Safety Improvement Plan

Misdiagnosis is an issue in the medical field and, most of the time, results in negative consequences for the patient’s health. That is according to the National Academy of Medicine. Approximately 12.1 million of the inhabitants of the United States have medical mistakes, and almost 10% of those mistakes are greatly awful or fatal mistakes that are very bad or can even cause death (Rodziewicz et al., 202). Thus, this kind of NURS FPX 4020 Assessment 2 offers several primary objectives: identifying why diagnostic mistakes occur and developing a safety measure consistent with proof to lessen these risks. Many different things can be done to enhance assessment and thus help healthcare workers understand what is going on and make better use of what they already have in their possession.

NURS FPX 4020 Assessment 2 Analysis of Root Cause

Information related to diagnostic errors is critical in that these mistakes are costly in healthcare organizations because patients receive the wrong or delayed treatment. A root cause analysis of this issue reveals that misinterpretation of the clinical information, heuristics, and ineffective cooperation among the members of healthcare organizations are the primary reasons (Payne et al., 2023). It also has adverse findings, such as nurses and doctors failing to relay patient information to one another or other members of the care team, which may lead to missed or incorrect diagnoses (Richens et al., 2020). Issues that come from the system, for example, lack of diagnosis equipment or the lack of time, lead to diagnostic errors as well (Jain et al., 2021). These mistakes occur primarily due to the workload and absence of specifics in medical practice; therefore, the timing of evaluation is less appropriate and less precise.

Root Cause Analysis and Improvement

These diagnostic errors occur for several reasons in a company. My last concern is that cognitive biases such as organizing and the tendency to come to conclusions early can limit a doctor’s view by making him or her concentrate on one direction. Second, when HCWs can communicate with each other, key patient information may never be transmitted or may be transmitted inappropriately (Smith et al., 2020). Third, doctors can never compare findings with evidence-based standards as much as they would love to do so, mostly because there are no clinical decision-support tools to do it for them. Fourth, inadequate access to diagnostic tools or being too slow to receive results can help delay and inaccurately diagnose issues (Richards et al., 2021). Finally, NURS FPX 4020 Assessment 2 structural factors such as shortage of human resources and working under pressure increase the chances of wrong diagnosis because the doctors are compromised by inadequate staff and working under tight time constraints.

Application of Evidence-Based Strategies

To remove medical errors, enhance patient safety, and bend the healthcare cost trend has called for the implementation of evidence-based practices and research. Doctors should employ Clinical Decision Support Systems, or CDSS, which provide the user with recommendations derived from the patient data and proven medical suggestions in real time. Rodziewicz et al. (2024) also mention cognitive errors can be minimized, and a better assessment can be made by NURS FPX 4020 Assessment 2 integrating CDSS within usual clinical activities. This method increases the reliability of diagnosis by comparing the manifestations of a particular illness in each client with regular indicators. This helps to narrow down the possibilities of reaching the wrong conclusion or even totally missing it.

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Another helpful method is to bring together individuals in order to discuss different topics from different fields. Something that can help with handing off patients is the SBAR structure (Davis et al., 2023): SWOT. NURS FPX 4020 Assessment 2 systemized pattern ensures that the right diagnostic information is passed correctly among the team members, thus decreasing the likelihood of diagnosis being further delayed (Stabile et al., 2019). Clear communication between nurses, doctors, and other healthcare workers ensures that the healthcare issue is addressed as soon as the slightest sign of illness is attained, reducing medical errors.

NURS FPX 4020 Assessment 2 Applying Simulation-Based Training

Finally, applying simulation-based training means that doctors and/or nurses can polish their medical skills in places where they will not harm anyone or cause further complications. Recurrent of this type of training could assist doctors in diagnosing the problems related to diagnosis more efficiently, resulting in improved patient outcomes and greater safety measures (Hodkinson et al., 2020). Knowing, using, and keeping these methods in practice lowers the rates of medical mistakes significantly once in a while. Hospitals, in consequence, improve patients’ treatment, reduce negative outcomes, and spare money on unnecessary treatments.

Safety Enhancement Plan

To enhance patient safety and prevent medication errors, Valley Ways Hospital will implement evidence-based strategies:

1. 1. Enhanced Medication Labeling: The hospital will implement new medication labeling with improved readability through color coding, clear typography, and larger fonts (Verhagen et al., 2022).

1. 1. Double-Check Protocol: A protocol requiring nurses to verify medication orders with physicians and independently check medication labels will be implemented for high-risk drugs like Heparin (Verhagen et al., 2022).

1. 1. Staff Training and Education: Medical staff will receive comprehensive training on the new medication system, emphasizing double-checking procedures, communication, and error reporting (Verhagen et al., 2022).

1. 1. Technology Integration: The hospital plans to implement barcode scanning technology to match medication labels and patient records, reducing the risk of medication errors (Verhagen et al., 2022).

Valley Ways Hospital places patient safety above all else, and the recent medication error involving Mr. Johnson serves as a reminder of the need for ongoing improvements in medication administration practices. The hospital is committed to implementing evidence-based strategies that will prevent medication errors, enhance patient safety, and prevent similar incidents from occurring in the future.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Finding a practical and evidence-based solution for minimizing the risk of diagnosis mistakes is much more complex. The undertaking of CDSS involves several steps, and the first step is crucial. According to Mebrahtu et al. (2021), this technology will provide live medical advice, as the article suggests. This will assist in reducing the chances of making decisions based on cognitive errors when making a professional decision. NURS FPX 4020 Assessment 2 incorporation of CDSS in a clinician’s daily professional work activity will help enhance the accuracy of diagnosis or provide ideas grounded on evidence and compare signs and analyses with the tests, making it very difficult for mistakes to happen.

SBAR Durig Handoffs

Second, it means that worsening communication between healthcare workers has to be addressed and improved. The use of SBAR during handoffs will help improve the correct and consistent identification of patients at risk (Davis et al., 2023). This kind of talking reduces the chances of misunderstanding, which facilitates the hospital’s operation since the nurses, doctors, and other members of the team can understand each other better, hence improving the doctors’ ability to diagnose.

Third, part of the plan to improve things is to initiate regular training sessions for the healthcare workers, involving the majority using a simulation. According to Khamparia et al. (2021), such training will enhance the doctor’s assessment competence and capability to deal with such scenarios. It also offers the advantage of preparing the healthcare teams to be ready in case of situations that would facilitate chances of wrong diagnosis. The plan will successfully reduce diagnostic mistakes, improve patient safety, and lower healthcare costs by using these strategies that have been shown to work: CDSS integration, better organizational communication systems, and simulation education models.

Existing Organizational Resources

Enhancing a safety improvement plan that concerns diagnostic mistakes has to be done using what the company already has. Essentially, the Electronic Health Record (EHR) system, for which CDSS operates in partnership, is a very effective tool in the initial stage. This combination allows the doctor to seek assistance in diagnosing a situation, which in turn helps him/her to make the right decisions (Schiff et al., 2022). NURS FPX 4020 Assessment 2 advantage of EHRs is that the knowledge amassed in them is enormous regarding each patient; therefore, doctors can obtain full records containing a great deal of data that would be useful to avoid mistaken diagnoses. This is why it is very important to prioritize this combination since it enhances the capacity to diagnose accurately and protect patients’ lives.

Valuable Resource Group

Another valuable resource is the system of the group’s multidisciplinary teams. System-driven communication templates like SBAR (Situation, Background, Assessment, and Recommendation) assist people in engaging better and ensuring that information is handed over in a proper manner when transferring shifts. This resource is valuable because it will immediately enhance the communication between the nurses, doctors, and many more staff members. This is important to overcome the time period wasted in diagnosing the correct color and texture of ceramic tiles.

The third type refers to training centers that make use of existing risk simulations. These places allow various healthcare practitioners to simulate the nature of scenes they are likely to encounter in real-life situations so that they may improve in cases where they may be weak in making diagnoses. Making simulation training programs a priority ensures that doctors are prepared to deal with complex scenarios that would otherwise lead to errors (Mebrahtu et al., 2021). The three most important things that could be done for patient safety include enhancing the alignment of CDSS with EHRs, improving communication among the teams, and providing more practice to the teams.

Conclusion

Diagnostic errors are among the main safety concerns that require an effective and systematic approach. To reduce medical errors in healthcare organizations, the organization must first employ an analysis that identifies the cause and which could be followed by the implementation of approaches based on evidence, such as the adoption of the Clinical Decision Support System (CDSS), improved information exchange between health professionals, and utilization of simulation-based training. Therefore, NURS FPX 4020 Assessment 2 advances medical accuracy and patient results, efforts that can be made entail applying existing tools like EHRs and models of collaboration. Ultimately, such endeavours will result in patient safety, and reduced healthcare costs and predispose the concept of the creation of always better in any health situation.

References

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