NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan NURS-FPX 4020 Improving Quality of Care and Patient Safety Root-Cause Analysis and Safety Improvement Plan
Inadequate patient education is a common quality and safety concern in the healthcare sector. This Root-Cause Analysis (RCA) is performed to analyze a clinical scenario where a lack of patient education led to harmful consequences for a patient at Miami Valley Hospital. This assessment analyzes the root causes of the situation, applies evidence-based best practices to address the concern, develops a safety improvement plan for the particular organization, and identifies the existing organizational resources to address the concern using the proposed safety improvement plan successfully.
Analysis of the Root Cause
The case scenario for this assessment is from the Miami Valley Hospital. On November 15, 2023, Olivia, a registered nurse, discharged her patient, Mary, who was recently diagnosed with diabetes. To control her hyperglycemia, Mary was prescribed insulin as take-home medication. Her discharge prescription stated to administer She was ten units of insulin Lantus at night.
Since Olivia had a hectic shift managing five chronic patients, she could not adequately instruct Mary on using insulin pens. A few days later, the patient was received in the emergency room for fluctuating blood glucose levels. Upon investigation, the emergency team identified that the patient had inadvertently taken incorrect doses of insulin while failing to recognize hypoglycemia symptoms. The problem significantly impacted patient safety by risking her for complications related to hyperglycemia and hypoglycemia.
While analyzing the situation, we can infer that adequate patient education is necessary to avoid several medical errors, ultimately preventing patient health complications related to medication action and utilization. A study states inadequate medication education is a significant patient safety and quality concern (T et al., 2022). Some root causes of the situation are inadequate patient education, staff workload, and ineffective nurse-patient communication. Lack of patient education is a systemic issue persisting in all healthcare settings.
Adequate patient education is essential to improve patient outcomes, enhance patient experiences, and reduce healthcare costs by encouraging patient engagement (Johnson et al., 2023). Conversely, a lack of patient education may lead to poor health behaviors, eventually making room for health complications. Secondly, nurses’ workload is contemplated as an essential root cause for both inadequate patient education and medication errors. Banda et al. (2022) presented a study showing that nurses’ workload directly impacts patient safety. These effects include poor care quality, lack of patient engagement, and medical errors. It also leads to insufficient nurse-patient communication, another root cause for inadequate patient education, stemming from the nurse’s busy schedule managing multiple chronic patients.
Effective communication between nurses and patients increases patient engagement in healthcare, ultimately improving patients’ adherence to medication and treatment plans (Kwame & Petrucka, 2021). Communication is essential to ensure healthcare providers and patients work on shared goals to lessen uncertain circumstances and enhance patient safety.
Evidenced-Based and Best Practice Strategies
Several evidence-based best practices are suggested by literature to address the quality and safety concerns of inadequate patient education and the root causes identified in RCA. These include establishing a patient-centered communication model, task delegation, and integrating patient education portals in the Electronic Health Records (EHR) system.
Task Delegation
Delegating nurses’ tasks allows them to distribute the workload effectively, which assists them in focusing on essential tasks that require nursing competencies (Crevacore et al., 2023). According to the literature, nurses’ workload significantly impacts patient education as it doesn’t allow nurses to efficiently engage patients in their healthcare (Akhtar et al., 2019). Therefore, delegating tasks allows nurses to allocate more time to patient care and education. Moreover, task division enables nurses to focus on their expertise, leading to more effective and tailored patient education. This way, it will address the patient safety issue of inadequate education.
EHR Patient Education Portals
Another evidence-based best practice to improve patient education is integrating patient portals into the EHR system. These portals provide holistic access to patients’ records, medication regimens, appointments, telehealth visits, and educational materials, allowing patients to receive comprehensive knowledge and make informed decisions about t