2 Root-Cause Analysis and Safety Improvement Plan Root-cause analysis (RCA) is a vital tool used in healthcare to uncover the underlying causes of evil occurrences or problems. Root-cause analysis (RCA) aims to identify the leading causes of unfavorable incidents and near-misses, making it easier to create preventative measures. RCA provides an organized and methodical approach to investigating sentinel events, which are unanticipated incidents that result in patient mortality, substantial bodily or psychological impairment, or the possibility of such harm (Liepelt et al., 2023). This particular RCA focuses on inadequate pain management as a healthcare setting sentinel occurrence. Inadequate pain treatment can greatly impact the general health, contentment, and recuperation of patients. The incident selected for analysis occurred in a medical facility where a patient's pain was not adequately evaluated or treated after surgery, resulting in an extended hospital stay and lower patient satisfaction. This paper details and analyzes cases of inadequate pain treatment and addresses evidence-based pain management solutions, concluding with a safety improvement strategy that utilizes current organizational resources to address this crucial issue. Analysis of the Root Cause Inadequate pain management is a common occurrence in healthcare settings, which raises serious concerns about patient safety and treatment quality. A complex problem, inadequate pain management can have detrimental effects on patients' health, ranging from discomfort to a longer recovery period or more serious problems. Insufficient pain treatment for a patient following surgery is the subject of the sentinel event under examination. Even with the availability of efficient treatment alternatives, many patients in hospital settings continue to have unmanaged or insufficiently treated pain (Germossa
3 et al., 2019). A recent event involved an underestimation of the postoperative patient's pain threshold, which resulted in insufficient pain medication. A nurse noticed this problem for the first time during a regular examination when the patient complained of unusually high pain even though they were taking their prescribed painkillers. The patient was the main victim of the issue, which resulted in excruciating pain and possible delays in healing. It also indirectly impacted the medical staff since it made a reevaluation of patient care plans and pain management procedures necessary. The usual protocol for managing pain following surgery did not work in this case. The patient's pain was anticipated to be sufficiently managed by following the recommended pain management strategy. Nevertheless, it appears that the pain treatment regimen was either not tailored to the individual needs of this patient or the stages were not followed to the letter. The RCA team's examination revealed that several variables had a role in this pain management failure. Usually, the procedure entails a precise evaluation of pain by nursing professionals, which is succeeded by delivering suitable medicine. In this instance, the patient's pain levels were not accurately assessed. Environmental stresses, including high patient-to-nurse ratios and little time for in-depth examinations, were contributing causes. A close examination was also given of the function of tools and resources, including the availability and application of instruments for evaluating pain. The event happened while staff training on these instruments was outdated, which might have resulted in abuse or underuse. Moreover, a major overlook was the lack of a systematic procedure for raising pain management concerns when the first therapies fail. Another important aspect was disruptions in communication. This involves potential misunderstandings concerning the patient's pain level and the healthcare team's care plan
4 between the patient and other team members. Regarding the patient's degree of pain and the failure of the first pain management strategy, there was a lack of communication between the treating physicians and the nursing staff. The patient's discomfort was not well managed due in part to the staff's workload, perhaps exhaustion, and a lack of good communication. Application of Evidence-Based Strategies Several factors that lead to insufficient pain management are highlighted by pain management research. Research has shown that underestimating and improperly assessing pain by medical practitioners is one of the main causes of ineffective pain management. Undervaluing patient-reported pain levels and a lack of thorough training in pain assessment are common causes of this problem. When nurses and doctors underestimate patients' self-reported pain, they frequently receive less-than-ideal pain treatment. This undervaluation may result in using the wrong dose or pain control strategies. Enhancing pain treatment requ
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