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Assessment 2: Root Cause Analysis and Safety Improvement Plan

Student Name

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Capella University

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Course Name

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Prof Name
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April 2, 2024
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Root Cause Analysis and Safety Improvement Plan

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Underlying driver Investigation (RCA) fills in as a compelling technique for distinguishing

factors adding to patient dangers. The medical care association viable has seen an
outstanding pervasiveness of drug organization issues and unfavorable occasions,
featuring the basic significance of patient wellbeing. RCA assumes a urgent part in
relieving preventable unfriendly occasions, upgrading patient wellbeing measures, and
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encouraging learning and quality enhancements inside medical care settings.
Outstandingly, drug mistakes, especially in organization, rank as the eighth driving
reason for death in the USA. Various examinations highlight drug organization blunders
(MAEs) as noticeable supporters of patient dangers in intense consideration settings,
prompting delayed clinic stays (Samsiah et al., 2020). This survey explicitly digs into the
underlying drivers of medication organization mistakes in the diabetic ward, zeroing in
on proof based wellbeing improvement systems and authoritative mediations to support
patient security.

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Analysis of the Root Cause

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Mr. Wallace's involvement with the diabetes ward reflects different underlying drivers of
prescription organization mistakes. Factors talked about in Evaluation 1 incorporate

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deficient preparation, deviation from prescription organization rules, deficient work
insight, interferences during organization, correspondence shortcomings, absence of

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information, and human variables adding to mistakes affecting patient wellbeing (Ulrich

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et al., 2022; Schroers et al., 2020; Wondmieneh et al., 2020). Studies uncover a positive
relationship between's nursing staff insight and the nature of patient consideration,
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underscoring the meaning of progressing preparing (Ulrich et al., 2022).
Correspondence holes among medical care experts, including attendants, clinicians,
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and partners, frequently bring about medicine organization mistakes (Samsiah et al.,
2020).
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Subjective evaluations feature a pervasive absence of prescription information among

medical caretakers, underscoring the requirement for designated intercessions
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(Schroers et al., 2020). Deviation from rules and the shortfall of suitable conventions
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fundamentally raise the gamble of drug blunders (Wondmieneh et al., 2020). Limiting
interferences during organization processes is pivotal, and human factors, for example,
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work pressure, solution mistakes, and absence of involvement contribute considerably

to MAEs (Brigitta and Dhamanti, 2020).
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Application of Evidence-Based Strategies

To address snags adding to somewhere safe and secure issues related with drug
organization mistakes, proof based techniques are basic. Nurture preparing and training
assume a significant part in lessening mistakes, with an emphasis on the "five rights" of

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drug organization (Yoon and Sohng, 2021). Carrying out Scanner tag Medication
Organization (BCMA) frameworks essentially diminishes the probability of managerial
slip-ups (Fitzhenry et al., 2020). Brilliant mixture siphons with Portion Blunder Decrease
Frameworks (DERS) and Clinical Choice Help (Compact discs) Frameworks add to
mistake decrease during drug organization (Melton et al., 2019). Developing a security
culture, open correspondence, and non-correctional detailing methodology are
fundamental for tending to blunders and upgrading patient wellbeing.

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Evidence-Based Safety Improvement Plans

Security improvement plans intend to decrease blunders prompting antagonistic

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occasions through the deliberate coordination of underlying driver investigation and
various arrangement techniques. Laying out a fault free culture underscores tending to

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the reasons for blunders as opposed to crediting fault, working with ideal mediations,
and forestalling morbidities (Carver and Hipskind, 2019). Compelling correspondence

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and joint effort between medical services experts emphatically influence the nature of

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patient consideration (Visvalingam et al., 2023).
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Root-Cause Analysis and Safety Improvement Plan
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Carrying out mechanical apparatuses, for example, BCMA and CDSS smoothes out
drug organization, guaranteeing exact records. The Lean Six Sigma In addition to
philosophy, zeroing in on process normalization and waste decrease, demonstrates
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important in clinics for limiting blunders (McDermott et al., 2022).

Organizational Resources
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Ideal use of existing and potential authoritative assets is fundamental for greatest effect.
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Medical clinics ought to put resources into staff preparing, innovatively progressed
instruments, and systems for patient consideration. Monetary assets can uphold staff
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preparing and the fuse of mechanical instruments. Including multidisciplinary groups

and expert associations improves normalization and best practices, at last decreasing
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unfavorable occasions.

Conclusion

Drug blunders in intense consideration settings require precise underlying driver

examination to forestall future events. Proof based approaches, like the LSS strategy,

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give thorough arrangements. Utilizing associations like Nursing Affiliations and MSOS
boosts the effect of wellbeing improvement plans.

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References

Carver, N., & Hipskind, J. E. (2019). Medical Error. StatPearls Publishing.

FitzHenry, F., et al. (2020). Prevalence and risk factors for opioid-induced constipation in
an older national Veteran cohort. Pain Research and Management, 2020.

McDermott, O., et al. (2022). Lean Six Sigma in healthcare: A systematic literature
review on motivations and benefits. Processes, 10(10).

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Melton, K. R., et al. (2019). Smart pumps improve medication safety but increase alert

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burden in neonatal care. BMC Medical Informatics and Decision Making, 19(1).

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Samsiah, A., et al. (2020). Knowledge, perceived barriers and facilitators of medication
error reporting: a quantitative survey in Malaysian primary care clinics. International

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Journal of Clinical Pharmacy, 42(4).

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Schroers, G., et al. (2020). Nurses’ perceived causes of medication administration
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errors: A qualitative systematic review. The Joint Commission Journal on Quality and
Patient Safety, 47(1).
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Ulrich, B., et al. (2022). National Nurse Work Environments – October 2021: A Status
Report. Critical Care Nurse, 42(5).
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Visvalingam, P. A. A., et al. (2023). A systematic review of knowledge, attitude, practice

and the associated factors of medication error among registered nurses. IJFMR –
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International Journal for Multidisciplinary Research, 5(4).

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Wondmieneh, A., et al. (2020). Medication administration errors and contributing factors
among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC
Nursing, 19(4).
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Yoon, S., & Sohng, K. (2021). Factors causing medication errors in an electronic
reporting system. Nursing Open.

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