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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

Root-Cause Analysis and Safety Improvement Plan

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.


Analysis of the Root Cause

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.

Application of Evidence-Based Strategies

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.

Improvement Plan with Evidence-Based and Best-Practice Strategies

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.

Existing Organizational Resources

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?

Conclusion

References

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.

English 101

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Assignment Guide: The Personal Narrative

Assignment Prompt

For this assignment, you will be writing a personal narrative–a story–illustrating an event or experience exemplifying gratitude. In other words, share a colorful story about an experience or event for which–either during or after the event– you feel or felt thankful.  

An example might be writing about your experience as a senior in high school and the teacher who  helped you to achieve your goal of graduating and attending college.  Another example might be writing a story about your experience growing up in a rural community, acknowledging that it was this small, but mighty, community that made you who you are today, and for this, you are thankful.  Sharing a story about a loved one whose influence has been meaningful to you in some way, and thus, you feel so very thankful for their role in your life, or in that particular experience, would also be an example. FInally, 
drafting a story about any experience in your life for which you are thankful it occured would be a great topic to explore for this narrative assignment. 

Assignment-Specific Requirements:

Length: This assignment should be at least 550 words. 


Thesis

: Underline your descriptive 
thesis statement or the point of your story.

Sources/

Evidence

 Needed:  No outside/
secondary sources are needed.

Page Formatting: See 
Appendix C – Formatting and Submitting Your Work


MLA

 Requirements: See 
Formatting your Essay: MLA 8th Edition

Rhetorical Mode

A personal narrative is a story about you. Narrative, from the Latin 
narrare, means to narrate a tale or a story. The narrative you will write will be a “personal” narrative.  Thus, the story will be written by you, about you, and in a lot of ways, for you. What makes a personal narrative so interesting is that it’s a story with a point or purpose.   In other words, a personal narrative is detailed, descriptive, 
dialogue-driven, and determined to make a point. 

Rhetorical Considerations

Purpose:

There needs to be a reason, not only for writing the narrative, but also for why the 
reader should read it. The purpose of the personal narrative is to share a meaningful experience and the lesson learned from the experience. Specifically, the purpose of this essay is to share a story about a time you experienced gratitude.

Audience:

In many ways, we write a personal narrative for ourselves to reflect upon an experience, to grow from an event. However, we want you to imagine that your 
audience is not only you but someone else. The writer needs to know who their 
audience is and how their needs will affect the way the narrative is composed and presented. For example, in addition to writing this story as an opportunity for personal reflection, you may also choose a family member or friend group as your real or imagined 
audience.  Selecting a real or imagined 
audience will help you develop your essay with the right 
tone. The 
tone for a personal narrative can be formal or informal; it really depends on your chosen 
audience. 

Form:

This piece of writing will be presented using a story format.  It will have a beginning, middle, and end.  The story will be written with a clear 
introduction paragraph, a body of 
story-development paragraphs, and a concluding paragraph. While a personal narrative is less “formal” than traditional academic writing, your story should have a 
thesis statement. Thus allowing the 
reader to truly understand the point of your story.

Six Features of a Personal Narrative

1.
Essay 

Organization

: The Personal Narrative is organized with a clear beginning, middle, and end. It should read like a story–with an 
exposition, a 
rise action, a 
climax, a 
falling action and a 
resolution or denouement.  While the Personal Narrative is certainly less formal than other academic essays, the point or moral of the story (i.e. the 
thesis) should be very clear to the 
reader.

2.

Transition

s: The Personal Narrative utilizes 
paragraph breaks and 
transitional words and phrases that help the 
audience (or 
reader) flow in and around the story. Read more about paragraph 
transitions in Appendix A. 

3.
Character 

Description

:  Develop the 
characters in the story so that the 
reader has a clear understanding of the people in the story–even if the one person in the story is YOU. Help your 
reader learn about the 
characters both by what they say and by what they do.

4.
Sensory Details: Develop a sense of 
imagery within the story using sensory-driven details. In other words, create a vivid story by helping the 
reader to see, hear, taste and touch just as the 
characters in your story do. Sensory details bring your readers into the story–into the experience you are sharing with them.

5.

Dialogue

: Use internal and/or external 
dialogue to connect the 
characters and help propel the story forward. 
Dialogue helps the writer to “show” rather than “tell” the story to the 
reader.  Tips for formatting 
dialogue can be found in Appendix C. 

6.
The 

Thesis
 (the message driving your story): Your story’s point or purpose should be structured as a 
thesis statement. And this statement should be underlined.  As the direction of your story must be made clear to the 
reader, it would naturally make sense that the point of your story or 
thesis appear somewhere within the first paragraph.   

Last modified: Friday, February 25, 2022, 1:58 PM

EVIDENCE-BASED PROJECT, PART 1: IDENTIFYING RESEARCH METHODOLOGIES

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EVIDENCE-BASED PROJECT, PART 1: IDENTIFYING RESEARCH METHODOLOGIES

Is there a difference between “common practice” and “best practice”?

When you first went to work for your current organization, experienced colleagues may have shared with you details about processes and procedures. Perhaps you even attended an orientation session to brief you on these matters. As a “rookie,” you likely kept the nature of your questions to those with answers that would best help you perform your new role.

Over time and with experience, perhaps you recognized aspects of these processes and procedures that you wanted to question further. This is the realm of clinical inquiry.

Clinical inquiry is the practice of asking questions about clinical practice. To continuously improve patient care, all nurses should consistently use clinical inquiry to question why they are doing something the way they are doing it. Do they know why it is done this way, or is it just because we have always done it this way? Is it a common practice or a best practice?

In this Assignment, you will identify clinical areas of interest and inquiry and practice searching for research in support of maintaining or changing these practices. You will also analyze this research to compare research methodologies employed.

To Prepare:

· Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry. Keep in mind that the clinical issue you identify for your research will stay the same for the entire course. 

· Based on the clinical issue of interest and using keywords related to the clinical issue of interest, search at least four different databases in the Walden Library to identify at least four relevant peer-reviewed articles related to your clinical issue of interest. You should not be using systematic reviews for this assignment, select original research articles.

· Review the results of your peer-reviewed research and reflect on the process of using an unfiltered database to search for peer-reviewed research.

· Reflect on the types of research methodologies contained in the four relevant peer-reviewed articles you selected.

Part 1: Identifying Research Methodologies

After reading each of the four peer-reviewed articles you selected, use the Matrix Worksheet template to analyze the methodologies applied in each of the four peer-reviewed articles. Your analysis should include the following:

· The full citation of each peer-reviewed article in APA format.

· A brief (1-paragraph) statement explaining why you chose this peer-reviewed article and/or how it relates to your clinical issue of interest, including a brief explanation of the ethics of research related to your clinical issue of interest.

· A brief (1-2 paragraph) description of the aims of the research of each peer-reviewed article.

· A brief (1-2 paragraph) description of the research methodology used. Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.

· A brief (1- to 2-paragraph) description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.

Nursing Assignment, NO PLAGARISM

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Midterm Paper Information

Your midterm paper will focus on healthcare fraud & abuse.  Unfortunately, there is an abundance of unsavory activities in the industry leading to a significant cost to the public.  A variety of regulatory agencies conduct investigations that can lead to significant penalty including monetary, recovery of funds, civil and criminal prosecution.  When cases are finalized, results determined, information is public.

Use the internet to search for cases.  Examples include oig.gov, civil monetary penalties, federal false claims act, Stark violations, anti kickback statute, qui tam (whistleblower) cases, healthcare fraud & abuse.  Select one or several cases.  Develop your paper 8-10 pages, double spaced, 12-14 font.  Include works cited for direct quotes.  Include the case specifics, what triggered the investigation & outcome.  At the end of your paper, discuss how you would approach a situation in your workplace in which you are suspicious of fraudulent activity.

Due October 14

Peer response

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Respond to two of your colleagues by recommending strategies to overcome the challenges your colleagues have identified. Support your recommendation with evidence-based literature and/or your own experiences with clients.

Response

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Respond using APA, at least 2 scholarly references

Leadership and a Healthy Work Environment

    Leadership involves the relationship between a leader and followers with the behaviors or attributes of the leader influencing whether employees consider a work environment to be healthy. Various theories exist about the way leaders and followers construct a social order in organizations leading to a healthy work environment (Vidman & Stromberg, 2020). My perception of a healthy work environment is one in which employees are satisfied with their work, work towards a common goal, and there is no conflict with managers or other employees. Leadership is the single most important factor influencing the employee’s work environment in an organization.

    One insight from the literature about leadership is that managers who inspire workers to do their best contribute to a healthy work environment. Transformational leadership theory proposes that the way leaders use a positive relationship with followers can inspire others to adopt a common goal and voluntarily work towards achieving the goal (Pourbarkhordari et al., 2016). An element of transformational leadership is inspirational motivation by the leader that involves encouraging and motivating employees. The concept of transformational literature gave me insight into the way a manager at a part time job where I worked was able to motivate employees. The manager was always optimistic about the future even when the job we were assigned seemed impossible to do in the time allowed. The manager helped us understand that if the staff worked together as an efficient team, we could meet the deadline even though it seemed difficult. The manager also showed us how to perform tasks more rapidly. Because of these behaviors, we felt like a team and were always focused on helping each other. Even though the work was difficult, the work environment seemed positive and friendly.

    I gained another insight about leadership from literature focusing on authentic leadership theory. The theory defines authentic leadership as altruistic and transparent behaviors, which also has an association with a healthy work environment (Giordano-Mulligan & Eckhardt, 2019). Authentic leaders consistently act on their values and beliefs and demonstrate integrity. The leadership approach also involves followers in decision-making about the best approach to perform tasks. On another part-time job that I once had, the manager was responsible for a group of employees that work her floor. A rule set by the manager was that all employees should be on time for work to avoid unfairly burdening the other employees. One of the employees, however, was always late. The manager terminated the employee and took the employees place until a replacement could be hired. The manager created a healthy work environment by fairly addressing a personnel problem consistent with stated values and beliefs while minimizing the burden of the decision on other employees.   

References

Giordano-Mulligan, M., & Eckhardt, S. (2019). Authentic nurse leadership conceptual framework. Nurse Administration, 43(2), 164-174. https://doi.org/10.1097/NAQ.0000000000000344    

Pourbarkhordari, A., Zhou, E., & Poukarimi, J. (2016). Role of transformational leadership in creating a healthy work environment in business setting. European Journal of Business and Management, 8(3), 57-70. https://core.ac.uk/download/pdf/234627054.pdf 

Vidman, A., & Stromberg, A. (2020).  Leadership for a healthy work environment- a question of who, what, and how. Leadership in health Services, 34(1), 1-15. https://doi.org/10.1108/LHS-06-2020-0041       

assessment 1 4050

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Assessment 1

Preliminary Care Coordination Plan

Instruction

Develop a 3-4 page preliminary care coordination plan for a selected health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

Introduction– The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

Preparation- As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Scenario

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

To prepare for this assessment, you may wish to:

· Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.

· Allow plenty of time to plan your chosen health care concern.

Instructions- Note: You are required to complete this assessment before Assessment 4.

Develop the Preliminary Care Coordination Plan

Complete the following:

· Identify a health concern as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs. Possible health concerns may include, but are not limited to:

· Stroke.

· Heart disease (high blood pressure, stroke, or heart failure).

· Home safety.

· Pulmonary disease (COPD or fibrotic lung disease).

· Orthopedic concerns (hip replacement or knee replacement).

· Cognitive impairment (Alzheimer's disease or dementia).

· Pain management.

· Mental health.

· Trauma.

· Identify available community resources for a safe and effective continuum of care.

Document Format and Length

· Your preliminary plan should be an APA scholarly paper, 3–4 pages in length.

· Remember to use active voice, this means being direct and writing concisely; as opposed to passive voice, which means writing with a tendency to wordiness.

· In your paper include possible community resources that can be used.

· Be sure to review the scoring guide to make sure all criteria are addressed in your paper.

· Study the subtle differences between basic, proficient, and distinguished.

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

· Analyze your selected health concern and the associated best practices for health improvement.

· Cite supporting evidence for best practices.

· Consider underlying assumptions and points of uncertainty in your analysis.

· Describe specific goals that should be established to address the health care problem.

· Identify available community resources for a safe and effective continuum of care.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

· Write with a specific purpose with your patient in mind.

· Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional requirements– Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

Portfolio Prompt: Save your presentation to your ePortfolio.

Course Competencies- By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

· Competency 1: Adapt care based on patient-centered and person-focused factors.

· Analyze a health concern and the associated best practices for health improvement.

· Competency 2: Collaborate with patients and family to achieve desired outcomes.

· Describe specific goals that should be established to address a selected health care problem.

· Competency 3: Create a satisfying patient experience.

· Identify available community resources for a safe and effective continuum of care.

· Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care.

· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

· Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

Scoring guide

Preliminary Care Coordination Plan Scoring Guide

CRITERIA

NON-PERFORMANCE

BASIC

PROFICIENT

DISTINGUISHED

Analyze a health concern and the associated best practices for health improvement.

Describe specific goals that should be established to address a selected health care problem.

Identify available community resources for a safe and effective continuum of care.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.

Apply APA formatting to in-text citations and references, exhibiting nearly flawless adherence to APA format.

safer opioid use

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Have you empowered a patient to believe they could make needed lifestyle modifications irrespective of the barriers that exist in their environment? Please provide examples. If so, you were engaged in health promotion activities as part of your nursing role.

Were there any strategies used in this simulation exercise that you use to improve patient health literacy? Are there any that you use that were not mentioned here? In your experience, how effective are these strategies?

What are some of the biggest challenges you encounter when trying to improve health literacy? What solutions can you offer to manage these challenges?

fundamentals M 5

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Concept Map: Respiratory Process

Top of Form

Bottom of Form

Module 05 Content

1.

Top of Form

Complete the
ATI Systems Disorder template for your assigned respiratory topic. Every box on the template must be completed, a citation is needed for every box, and your reference list must be included (APA). 

Case Soap Note

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Please see attachment