Assessment instructions The Quality Improvement Plan template has key sections to be completed, incl

Assessment instructions The Quality Improvement Plan template has key sections to be completed, including: word count 2000 1. Introduction – Provide a brief summary of the de-identified case study, context and clinical risk from Assessment 2. Briefly summarise the causal factors that lead to the incident or near miss identified in the root cause analysis (RCA) from Assessment 2 that are relevant to this quality improvement plan. Include a problem analysis of the clinical risk in the context of the Australian health care setting (i.e. nature of risk, relevance, prevalence, outcomes or impact). State the aim(s) and objective(s) of the quality improvement plan; 2. Quality Improvement Plan – Formulate a quality improvement plan that states 3 actions that will be implemented to address the area of clinical risk, outlining: who is responsible; required resources or methods; how it will be measured and evaluated; the links to relevant quality and safety standards and; the intended timeframe. Students are to tailor their recommendations to the context of the de-identified case study and use the root cause analysis (RCA) from Assessment 2 to inform their action plan; 3. Discussion: Discuss the strategies identified in the action plan and provide rationales with evidence to support your recommendations. Ensure to include the action taken, why certain people/roles were selected, resources and methods and means of evaluation; Link these strategies to the relevant quality and safety standards or other relevant clinical governance principles; Include in your discussion how clinical leadership and clinical management impacts the processes of quality improvement in this context. 4. Conclusion – Provide a brief conclusion that summaries your key points outlined in the report; and 5. Reference List – Provide a reference list of all sources used to support the assessment using APA 7th edition referencing guidelines. Scaffolding within the unit which supports students in this assessment: This assessment draws on content covered in modules 1-6. Students will utilise the clinical risk identified in the case study and associated root cause analysis (RCA) from Assessment 2 to inform their quality improvement plan. Slide 1: Introduction Purpose: Analyze a medication error to understand contributing factors and evaluate safety protocols. Objectives: Examine the incident through a detailed case study. Risk assesmeent Discuss contributing factors using root cause analysis. Reflect on personal and systemic readiness to enhance patient safety. Link findings to NSQHS Standards. Slide 2: Case Study Overview During a morning shift in the medical ward, a patient with diabetes was mistakenly given a higher dose of insulin than prescribed. The healthcare team involved included a junior nurse, senior nurse, and a student nurse. My role was to observe the situation and monitor the patient afterward. As a result of the incorrect dosage, the patient exhibited symptoms of hypoglycemia, such as a rapid heartbeat (tachycardia), headache and sweating. Fortunately, prompt treatment was administered, and the patient’s condition was stabilized successfully. Slide 3: Clinical Risk Identification In this risk assessment, I’ve categorized the likelihood of the event as “Unlikely,” there’s only a 1 to 20% chance it might occur during the activity. This indicates that while the event isn’t expected to happen frequently, it is still possible. The consequence of this event is considered “Moderate,” as there are some protocol breaches and the incident resulting in temporary injury to the patient. Moreover, it required medical intervention, but it didn’t cause long-term damage (Risk Matrix -Example, n.d.). The HARM score is 3 and indicates a moderate level of harm, as it requires careful monitoring and some medical intervention. The patient’s condition worsened slightly but it was manageable. To address this, we increase their level of care and closely monitor their blood glucose levels (BGL) and other symptoms every 15 minutes until they stabilize. Provide medical intervention, such as administering oral glucose to help stabilize their condition (Health, 2022). Slide 4: NSQHS Standard Standard 1 – Clinical Governance: The clinical risk is linked to this standard as it requires a robust governance framework to oversee and ensure adherence to medication safety protocols, preventing errors and ensuring patient safety. Standard 2 – Partnering with Consumers: The clinical risk connects to this standard because involving patients in understanding their medication and the correct dosages can help prevent errors and improve safety, making the patient an active participant in their care. Standard 4 – Medication Safety: This standard is directly related to managing the risk of medication errors. It emphasizes the importance of procedures such as double-checking dosages and ensuring accurate medication administration. Standard 6 – Communicating for Safety: Effective communication is crucial for preventing medication errors. This standard is relevant to the clinical risk as it highlights the need for clear and accurate communication among healthcare providers. Miscommunication, such as unclear handover notes or verbal instructions, can lead to incorrect medication administration (Australian Commission on Safety and Quality in Health Care, 2021) Slide 5: Root Cause Analysis For this incident, the RCA was visualized using a Fishbone Diagram, which focused on four key areas: People, Processes, Environment, and Materials. Under people the medication error was linked to inadequate training, over-reliance on technology, Poor handover and a lack of support for staff. These factors contributed to mistakes in medication handling due to unclear or incomplete communication between healthcare providers. In materials Improper storage of medications could have led to degradation or mix-ups. Inconsistent documentation made it difficult to track and verify medication details accurately. Inadequate labeling might have caused confusion about the medication’s identity or dosage. Additionally, faulty systems such as DHR that didn’t work, or it was broken, and it didn’t show the RedFlag. Under the process two key issues were identified. First, the double-checking protocol was not followed, insulin being high risk medication it is crucial steps to verify the medication and dosage which were skipped. Second, the medication guide was not adhered to, so the recommended procedures and safety checks were ignored. Lastly under environment the causes of error were Time pressure meant staff were rushing and might have made mistakes and ignore double checking. Work overload caused them to handle too many tasks at once, increasing the chance of errors. A distracting work environment made it hard to focus on medication tasks. Additionally, broken equipment barcode scanner may have malfunctioned, leading to errors (Ilie & Ciocoiu, 2010) Slide 6: Reflection on the Incident Using Gibbs’ Reflective Cycle, During my placement, I observed a medication error where the wrong insulin dose was administered, which made me feel anxious and concerned about the potential harm to the patient, as well as my own readiness to handle such critical situations. Upon reflection, I realized that while the senior nurse’s timely intervention mitigated the error, it highlighted significant gaps in our procedures. The incident emphasized the importance of clear communication and strict adherence to safety protocols (Sharon et al., 2024). From this, I concluded that I must prioritize medication safety, ensure effective communication, and engage in interprofessional teamwork. Moving forward, I plan to seek further training on medication safety, participate actively in communication briefings, and collaborate more closely with my healthcare team to improve patient safety (Lee & Quinn, 2019). Slide 7: Readiness for Safe Care This incident illuminated areas for personal and professional growth in my readiness to provide safe care: Career-long Learning: I recognize the importance of ongoing education to stay updated on safe practices, particularly in medication administration. Accountability: I need to be more accountable for my actions and take proactive steps to ensure patient safety, even in supervised settings. Leadership Readiness: As I gain more experience, I must develop the confidence to speak up when I observe potential risks or deviations from protocols. Teamwork: Collaboration with colleagues and effective communication is essential to prevent

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