NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety 

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

Root-Cause Analysis and Safety Improvement Plan In this assessment, we conduct a Root-cause Analysis (RCA) of the patient safety and quality issue at AdventHealth, Winter Park. The issue identified is inadequate pain management in healthcare settings, leading to poor patient outcomes and poor care quality. Through this RCA, we analyze the root causes of the scenario and present evidence-based best practices to address the quality and safety issues. This assessment establishes a safety improvement plan for the organization and elaborates on using organizational resources to implement the plan successfully.  Analysis of the Root Cause The scenario is about inadequate postoperative pain management for Ms. Johnson following her hip replacement surgery at AdventHealth, Winter Park. The surgical procedure was completed successfully, and Ms. Johnson was moved to the postoperative care unit to recover. However, the problem stemmed because of the surgeon’s inadequate communication with the nursing staff about postoperative instructions for pain management. In the recovery unit, Ms. Johnson was placed under the supervision of a novice nurse. She complained of severe pain a few hours later, rating it at an 8 out of 10 on the pain scale. However, an insufficient and imprecise pain assessment was conducted due to unskilled nursing staff. Due to the incorrect assessment and inadequate communication regarding post-operative pain management orders, the patient received her pain medication late, leading to prolonged discomfort and an all-around stressful situation.  The relevant finding of the root-cause analysis presents that adequate communication between the surgeon and nursing staff must be regarding postoperative pain management orders. Moreover, nurses should perform timely and accurate pain assessments and administer them promptly to ensure patient comfort. Several elements influence the situation. While the environmental factors include the busy and high-stress atmosphere of the postoperative care unit, human factors include nurses’ lack of expertise and education. Lastly, ineffective interaction and collaboration among healthcare providers are communication factors. The root causes of this issue appear to be the communication gap between the surgeon and nursing staff and lack of coordination (Atthayasai et al., 2023) among the nurses and pharmacists, which led to delayed administration of pain medication, compromising the overall quality of postoperative care. Additionally, novice nurses’ lack of experience and limited education in pain evaluation contributed to improper and incomplete pain assessment, resulting in patient discomfort and reduced satisfaction (Cao & Hull, 2021; Hämäläinen et al., 2022).  Evidenced-Based and Best Practice Strategies The literature suggests several evidence-based best practices to address inadequate pain management as a quality and safety issue in healthcare settings. These strategies are best suited to combat the communication, coordination, and educational challenges among healthcare professionals and patients. These include enhanced communication protocols, explicitly focusing on integrating the Electronic Health Records System (EHR), and comprehensive training programs for healthcare professionals. Enhanced Communication Protocols: Establishing standardized communication channels between healthcare providers to communicate important information about patients’ histories and current treatment is essential to address communication gaps and improve coordination (Oliveros et al., 2019). Moreover, this strategy focuses on integrating the EHR system for healthcare providers to document management plans accurately. These plans and comprehensive patient records are accessible to the interdisciplinary team involved in patient care. This approach enhances collaboration and prevents provider communication errors (Vos et al., 2020). Implementing standardized communication protocols between surgeons and nursing staff is beneficial in addressing inadequate pain management as it helps the seamless transmission of postoperative pain management plans and improves collaboration among healthcare providers.  NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan Comprehensive Training Programs: Developing and conducting training programs for nurses on effective pain evaluation that covers essential topics such as assessment techniques, use of pain medications and their side effects, and information on non-pharmacological strategies will enhance their abilities to provide patient-centered pain management and care (Evans, 2021). Including simulation exercises within the training programs enhances nurs