Root Cause Analysis

Quality and Safety Education for Nurses

NURS 490W- Nursing Leadership
Purpose of Assignment
To identify root cause problems which contribute to adverse patient outcomes.
Approach to Assignment
I wanted to explore a nursing intervention that is frequently done in different
practice settings, and look at current research to see what evidence based practices would
increase quality and safety measures for the patient. The intervention I chose was
endotracheal suctioning, and the population affected range from infants to the elderly.
Because this is a widely utilized intervention, I have also witnessed various protocols and
techniques being used. This assignment required me to research the best effective
methods that would enable good clinical practice.
Reason for Inclusion
If best practices are not widely practiced then interventions such as endotracheal
suctioning can contribute to adverse patient outcomes. There should be a standard of
practice for endotracheal suctioning that is implemented across all health care settings.
This is a safety issue that needs to be addressed so that health care providers can provide
the best clinical practice for their patients.
Nursing Practice

Performs direct and indirect therapeutic interventions that incorporate principles

of quality management and proper safety techniques based upon assessment
findings

This discussion board post assignment looked at research that provided evidence
on best practices for endotracheal suctioning. Research showed there was a need for
improvement in nurses using guidelines that were evidence-based instead of
traditional guidelines used in actual practice. Evidence-best practices, such as a
thorough respiratory assessment, were discussed as a intervention that improved
patient outcomes. A thorough respiratory assessment include the following steps:
patients respiratory rate, signs of labored breathing, adventitious lung sounds, quality
of cough to clear secretions, quantity and characteristics of secretions, any signs and
symptoms of infection, pulse oximeter reading, and if supportive equipment is
working properly. Strategies were also discussed to improve the suctioning procedure
and reduce potential complications.
Research

Evaluates research that focuses on the efficacy and effectiveness of nursing

interventions

Endotracheal suctioning is a nursing intervention that is routinely done in a variety of

health care settings. However, the actual practice does not always implement
evidence-based best practice. I reviewed a study on patients in critical care units
requiring mechanical ventilation and the best evidence based practices for
endotracheal suctioning. The study indicated that auscultation over the trachea and
ventilator waveforms were the best indicators of a patient needing endotracheal
suctioning.

Professionalism

Advocates for professional standards of practice using organizational and

political processes

In this assignment I discussed strategies to best implement standard of practice

regarding endotracheal suctioning. Strategies involved changing the standard of
practice guidelines in an organizations manual. The standard of practice guidelines
regarding endotracheal suctioning should be developed on scientific based evidence.
An emphasis was placed on improving quality of care by development of standard
practice guidelines and requiring nursing compliance of the organizations evidencebased best practices.