200 word case
DUE 9/15 7PM EST
- assignment criteria listed above.
Please use, at minimum three scholarly references, and your paper should be 300-words, excluding title and reference pages.
DUE 9/15 7PM EST
Please use, at minimum three scholarly references, and your paper should be 300-words, excluding title and reference pages.
2
2
Root-Cause Analysis and Safety Improvement Plan
Your Name
School of Nursing and Health Sciences, Capella University
NURS4020: Improving Quality of Care and Patient Safety
Instructor Name
Month, Year
Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.
Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:
· What happened?
· Who detected the problem/event?
· Who did the problem/event affect?
· How did it affect them?
Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:
· What was supposed to occur?
· Were there any steps that were not taken or did not happen as intended?
· What environmental factors (controllable and uncontrollable) had an influence?
· What equipment or resource factors had an influence?
· What human errors or factors may have contributed?
· Which communication factors may have contributed?
These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event.
Identity best practices strategies to address the safety issue or sentinel event.
· Describe what the literature states about the factors that lead to the safety issue.
· For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.
· Explain how the strategies could be addressed in safety issues or sentinel events.
Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain:
· Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
· Support these recommendations with references from the literature or professional best practices.
· A description of the goals or desired outcomes of these actions.
· A rough timeline of development and implementation for the plan.
Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.
· A brief note on resources that may need to be obtained for the success of the plan.
· Consider what existing resources may be leveraged to enhance the improvement plan?
Reference page should be double spaced throughout without extra spaces between entries.
Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.
Respond to the four colleagues
with preference to colleagues who selected different translation science frameworks or models from the one you chose. Recommend another framework/model they might consider and/or clarify their explanation of translation science. Cite sources to support your posts. PLEASE INCLUDE AT LEAST 2 REFERENCES OF EACH RESPONSE
1 . One of the prominent theories that has been very effective in the incorporation of learned information into action is the Knowledge to Action (KTA) model. Spooner et al. (2018) stated that this model is the conceptual layout recommended to help individuals perturbed by the process of knowledge implementation to evidence-based practice. Knowledge creation and action cycle are the two major parts of the KTA model used to translate the knowledge obtained into clinical settings and the barriers encountered during this process are based on the practice conditions. When the KTA model is utilized one can ascertain that the knowledge obtained is from reliable research with long-lasting outcomes (Spooner et al., 2018).
The ease of translation of knowledge to action is the reason the KTA model is more popular among clinicians. Working in the correctional facility as a Nurse Practitioner, allows me to see a variety of inmates from minor to more serious crimes. Most of these inmates suffer from different mental health disorders including Schizophrenia and Bipolar disorder and their manner of voicing their anger is significant. The complexity and interdisciplinary nature of correctional facilities necessitates a conceptual framework or model to help translate evidence-based information into action. Field et al. (2014) pointed out that the KTA framework was made to address the various complexities utilized in explaining the method of theory implementation into action. Achieving optimal health requires an increase in the quality of healthcare services and products delivered. Kastner and Straus (2012) opined that the information implementation process including synthesis, dispensing, interchange, and effective use is crucial in the advancement of healthcare
Relevancy To my practice
Due to the hierarchy in correctional facilities, working as a Nurse Practitioner in this space can be very demanding as the county sheriff is in charge of operations while the detention officers apply different rules in dealing with inmates with psychiatric illnesses. The “Use of Force” is the most likely used process by detention officers when managing violent and mental health patients and this unsafe practice can lead to injury on both parties. Moreover, utilizing force is dehumanizing, does not promote support, and is not a holistic approach. Although, assessing and stabilizing these types of patients can be tough for healthcare providers due to their presentation, abnormal vital signs, and violence against the care team. Relating the KTA model to my practice issue can be done by incorporating the two parts of the model the knowledge creation and the action cycle. For knowledge creation, pinpointing the “Use of force” as a limitation to the delivery of efficient care to inmates and the action part is the transformation model to dismiss the use of force. This action promotes social support in the setting and the change team consists of sergeants, nurses, nurse practitioners, and several mental health professionals. A specific example of the effective use of the KTA model was highlighted when a bipolar patient was accompanied to the clinic due to a psychotic episode. The patient had refused to respond to the officer's question during intake and was identified as a high risk for suicidal ideation/attempt. While the suicidal process was being implemented the patient became violent and aggressive. The change team took over the situation and incorporated the “action cycle” of the KTA model by leading the inmate to a quiet area and reassuring him of his safety. This deed by changing them caused the patient to become compliant with his admission and provided willingly all the needed information for the process. Horesh and brown (2020) emphasized that there is an imminent need to close the disparaging gaps in care delivery in major areas as the care team addresses the barriers and creates innovative ways to support individuals in need.
2 . The translation science framework/model I chose is the Iowa model for Evidence-based Practice framework because of the detailed algorithm. The Iowa Model algorithm is user-friendly and straightforward, guiding nurses to use research to improve care. The Iowa Model centers around complete organizational support for transitioning current practices with top priority triggers to current evidence-based practice. The model is designed as a pilot test instead of an instant practice change. The process begins with stating the trigger or purpose identified. The process then determines if it is a priority; once established as a priority, the next step is addressed. This step includes appraising and analyzing the evidence and determining if there is sufficient evidence. If the answer is yes to the sufficient evidence question, the design of the pilot is developed. Once the pilot is appropriate for a change in practice, the change is implemented.
An example of a trigger appropriate for the Iowa Model use is the change in practice for pressure ulcers. The organization accepts pressure ulcers as a top priority. The next step is evidence-based practice research and determining if the information is substantial. Once evidence is validated as appropriate, the design pilot integrating pressure ulcer preventative equipment is developed. Once approved, the pilot is evaluated again for appropriateness and implemented into practice. In conclusion, I chose this model because of the straightforward algorithm.
3 : The integration of evidenced-based strategies into practice can be challenging, especially in behavioral health. Knowledge translation frameworks provide a systematic approach for translating knowledge into practice, which promotes and sustains practice change (White et al., 2019). The knowledge-to-action (KTA) framework is one of the most popular conceptual frameworks used in healthcare settings to support the implementation of evidence-based practice (White et al., 2019). The framework incorporates existing change theories from health, social sciences, education, and management fields to provide user-friendly action phases to consider during the knowledge translation process.
The KTA framework comprises two components: knowledge creation and action. Knowledge creation is the production of knowledge and consists of three phases: knowledge inquiry, knowledge synthesis, and creation of knowledge for best practice (Davison et al., 2015). The Action component guides the implementation process for change and sustainability consisting of the following phases: identify the problem; adapt knowledge to the local context; assess barriers to knowledge use; select, tailor, and implement interventions; monitor knowledge use; evaluate outcomes; and sustain knowledge use (Davison et al., 2015).
The practice problem that I am looking to address issues facing mental healthcare that negatively affect access to mental health services (Andrade et al., 2014). Inequalities in health and social circumstances perpetuate social and economic exclusion that leads to unequal access to health and its determinants (Marmot et al., 2008). The utilization of the KTA model allows us to critically examine and support the move towards health equity by addressing the causes of health inequities in addition to acknowledging the gap between knowledge and action to improve health equity.
4.The Knowledge to Action (KTA) framework is a prominent concept that emphasizes translating research findings into practical therapeutic applications. The primary objective of this strategy is to prioritize evidence-based interventions, particularly in contexts where the effective dissemination of knowledge is of utmost importance (Spooner et al., 2018). The KTA framework is primarily centered around two fundamental processes: generating and disseminating knowledge, followed by its practical implementation. The applicability of this paradigm is contingent upon the specific characteristics of the context. Nevertheless, its primary objective is establishing long-term treatments grounded in rigorous research (Spooner et al., 2018).
Within the domain of critical care nursing, the interplay between generating knowledge and implementing practical insights holds immense value. Critical care units manage many situations, encompassing life-threatening disorders and post-operative care. The intricate and interdisciplinary character of critical care environments necessitates the development of a systematic framework that integrates evidence-based ideas into tangible interventions. Field et al. (2014) acknowledge that the KTA framework is appropriately structured to manage the complexities associated with knowledge translation effectively. To improve patient outcomes and the healthcare system, engaging in successful knowledge translation is crucial, which involves the ethical sharing and application of research findings (Kastner & Straus, 2012).
Application In My Practice
Managing the difficulties encountered in a critical care environment is inherently arduous. In this context, the potential consequences are significant, and the implementation of therapies based on timely and evidence-based practices can determine the outcome between survival and mortality. For example, the selection of ventilation systems, sepsis management approaches, and hemodynamic monitoring techniques necessitates a foundation in empirical research while also considering the unique requirements of each patient.
The KTA model, comprising the elements of “Learning Paths” and “Action Cycle,” provides a framework for implementing evidence-based practice in the critical care setting. During the initial stage of learning, it is imperative to find optimal methods or standards tailored to specific medical diseases such as acute respiratory distress syndrome (ARDS) or septic shock. In contrast, the “action” step involves the customization and execution of these optimal methodologies by individual patient circumstances.
Let us contemplate a hypothetical situation when a patient afflicted with septic shock exhibits an inadequate response to the initial administration of fluids for resuscitation purposes. By employing the Knowledge-to-Action (KTA) paradigm, a critical care nurse can effectively incorporate current research about initiating vasopressors. This approach allows for the adjustment of interventions based on empirical evidence while also considering the specific circumstances of the individual patient. The need for knowledge translation is heightened in healthcare teams as they confront increasing difficulties, particularly in high-pressure settings such as critical care units, where adherence to evidence-based treatment is crucial (Horesh & Brown, 2020).
Islam
Instructions:
In your reading of Chapter 12 –
Encountering Islam: The Straight Path of the One God you have gained a better understanding of what the religion of Islam is all about from the context of its history, sacred scriptures, beliefs and practices, code of ethics, etc. You will now use the information gleaned in the chapter to expand upon particular elements of Islam enumerated below:
1.
Islamic Symbols and Names (.5 pages)
A. Identify a common Islamic symbol and explain its significance
I. Consider the following:
1. History/Origins of the symbol
2. Important religious figure(s) associated with the symbol and their involvement with it
3. How is the symbol utilized by Muslims today?
A. Is it used during prayer/worship?
B. Is it worm as an outward sign of faith?
B. Distinguish between the terms 'Islam' and 'Muslim' as it relates to the Islamic faith
2.
Life of the Prophet Muhammed (.5-1 pages)
A. Discuss who the Prophet Muhammed was and the impact that he had on Islam.
B. Describe 2 key events from the Prophet Muhammed’s life.
C. Address how these events are commemorated by Muslims today
3.
Sacred Scriptures (.5 pages)
A. Analyze what the Qur’an is and assess upon how Muslims use it today
I. Consider the following:
1. Importance of particular Surahs in the Qur’an
2. How the sacred text came into existence
3. Important religious figures mentioned in the Qur’an
4.
Beliefs and Practices (2 – 3 pages)
In the religion of Islam there is set of beliefs that all Muslim’s must follow. These are known as the
Articles of Faith and their foundations are found in the Qur’an. The 6 articles of faith tell Muslims what to believe in and then the
5 Pillars of Islam explain how to implement these beliefs in their daily lives.
1.
A. Interpret the meaning of
each of the Six Articles of Faith
(1-1.5 pages)
I. Belief in the Oneness of Allah (God)
II. Belief in the Angels
III. Belief in the Books of Allah
IV. Belief in the Prophets of Allah
V. Belief in the Day of Judgement
VI. Belief in the Divine Decree – Will of Allah
B. Articulate the significance of
each of the Five Pillars of Islam listed below and demonstrate how these pillars are lived out by Muslims today
(1-1.5 pages)
I. Shahadah – Profession of Faith
II. Salah – Prayer
III. Zakah – Almsgiving
IV. Sawm – Fasting
V. Hajj – Pilgrimage
Submission Instructions:
· This report must be typed in 12 pt. Times New Roman font & double-spaced.
· Each section of the report must include a section title on a separate line (ex: Christian Symbols, Christianity in Context, etc.).
· Each section must incorporate at least 1 direct quotation from wither the course text (
World RELG4: Introduction to World Religions) .
· The paper should be formatted per current CMOS and adhere to the page length requirements outlined above.
PowerPoint presentation
Theme: Fluids and Electrolytes, Acids and Bases
12-15 slides
Define and describe Health equity. What are some of the problems and Risks factors associated with health equity. please do this in about 4 -5 bullet points.
EMERGING AND RE-EMERGING DISEASES FACT SHEET
Sir Francis Bacon said, “Knowledge is power.” This is most definitely true when it comes to diseases and how to prevent and treat them. As a nurse, you are charged with teaching patients how to prevent infectious diseases and what to do if they become infected. A powerful tool in your arsenal is the Fact Sheet. Usually comprised of one page of easy-to-read content, these leaflets can be distributed easily and can effectively inform your practice.
To prepare for this Assignment:
· Select one disease that is either emerging or re-emerging in the world today.
· Research the disease using both scholarly and non-scholarly resources.
· Determine your audience (patients, other nurses, schools, etc.) that you would want to share the Fact Sheet with.
· Select pieces of information that are appropriate for your audience.
Assignment Instructions:
Disease: Meningococcal Disease
Audience: General Public and Healthcare Professionals in Behavioral Health Settings
· Submit: A 1- to 2-page Fact Sheet.
· Indicate the audience on the Fact Sheet.
· Give a brief history of the disease.
· What are the implications of the spread of the disease?
· How does one detect and prevent the spread of this disease?
· How is this disease treated?
· Your Fact Sheet should be visually stimulating, appropriate for your audience, and formatted with bullet points for easy reading.
· Support your “facts” with at least 3 references.
Develop an individualized plan for addressing each of the 10 pyramid points. Describe how you will address each point and identify a specific schedule, place, and goal for studying. Reflect on ways to improve the plan you have developed.
GRADUATE PRIMARY CARE CLASS FOR FAMILY NURSE PRACTITIONER
11:59 PM
4 goals – each goal should be:
Specific
Measurable
Achievable
Relevant
Time-Bound.
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