Capella FPX 4035 Assessment 2

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

Understanding the Incident

A sentinel event is a critical patient safety issue that occurs unexpectedly and is not directly tied to a patient’s existing condition or illness. Such incidents often have profound effects on patients, their families, and healthcare staff. The primary purpose of a root-cause analysis (RCA) is to uncover both immediate and systemic failures contributing to these events to implement corrective strategies and prevent recurrence.

In one such incident at an Emergency Department (ED), a patient in septic shock experienced delayed treatment due to an incomplete handoff between nursing staff. The outgoing nurse failed to convey essential clinical details, compounded by inadequate documentation. As a result, the patient’s condition worsened, requiring prolonged hospitalization and additional interventions. The emotional toll on the patient and family, as well as the professional strain on staff, highlighted the need for stronger communication protocols and systems improvements.

Analyzing Contributing Factors

Root Causes and Contributing Elements

Human Elements: Nurse fatigue, communication breakdowns, and inadequate training in structured handoff practices played a major role. Overreliance on verbal exchanges without written backup increased risk.
Systemic Challenges: The chaotic ED environment, absence of digital tools for handoff, and understaffing created barriers to effective communication.
Organizational Culture: A weak culture of safety, lack of leadership reinforcement for handoff protocols, and limited routine audits exacerbated inconsistencies.
Cultural Influences: Language differences and varying communication norms among multicultural staff may have also interfered with message clarity.

Deviation from Standards

There were significant lapses in following established procedures, notably the SBAR (Situation, Background, Assessment, Recommendation) framework. The outgoing nurse’s verbal report lacked completeness, and no checks or clarifications were made by the incoming nurse. Documentation was also insufficient, omitting vital assessments and care plans.

Roles, Communication, and Environment

Personnel Involved

The event primarily involved the outgoing and incoming nurses, along with a physician who made new medication orders that were not communicated properly. Supervisors such as the charge nurse failed to ensure adherence to standard handoff procedures, and leadership lacked oversight in enforcing training and auditing practices.

Communication Breakdown

There was a clear communication gap between the nurses and the physician. Vital updates on patient condition and treatment changes were missed. Additionally, the patient was not adequately informed about their revised care plan, reducing their ability to engage meaningfully in their treatment.

Contributing Environment and Staffing

The physical layout of the facility—with distant nursing stations and frequent equipment malfunctions—created additional challenges. Staffing shortages overwhelmed available nurses, leading to skipped protocols. While staff competency was generally acceptable, gaps in targeted training for handoffs and updates on medication protocols were evident.

Organizational and Monitoring Shortfalls

Policy Failures

Even though policies for handoffs and medication administration existed, they were not followed. Their complexity and limited accessibility made consistent application difficult, leading to variance in practice.

Monitoring Gaps

The patient’s vital signs were not tracked consistently during critical hours, delaying responses to deterioration. Alarm fatigue also contributed, with important alerts being missed amidst frequent non-critical ones.

Recommendations and Safety Enhancements

Lessons and Improvement

To prevent recurrence, systemic upgrades are necessary. This includes standardizing communication tools, reinforcing training, and fostering a culture where staff feel comfortable speaking up. Implementation of electronic systems to track handoffs and patient monitoring can also reduce human error.

Patient Safety Measures

Introduce risk mitigation strategies like automated alerts for vital signs, regular simulation training, and robust alarm systems. Create a non-punitive feedback mechanism encouraging open reporting of errors to support learning and continuous quality improvement.

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Root Cause(s) and Contributing Factors

An in-depth analysis of the sentinel event revealed several underlying causes and contributing factors. One of the principal root causes was the failure in communication among healthcare team members. This lapse led to incorrect interpretation of the patient’s condition and delayed appropriate intervention. Categorized under Human Factor – Communication (HF-C), this failure represents a fundamental weakness in team coordination.

Another significant root cause was insufficient training related to newly updated protocols and equipment usage, which falls under Human Factor – Training (HF-T). This deficiency prevented staff from recognizing and responding effectively to changes in patient status.

A third contributing factor was equipment malfunction, which led to unrecognized warning signs and subsequently delayed clinical responses. This issue is associated with Environment/Equipment (E). Additionally, staff fatigue, linked to poorly structured schedules, affected cognitive performance and situational awareness, a problem that aligns with Human Factor – Fatigue/Scheduling (HF-F/S).

Moreover, breaches in established safety protocols and the presence of organizational barriers, such as ineffective communication systems, further exacerbated the incident. These challenges reflect issues in both Rules/Policies/Procedures (R) and Barriers (B) that need systematic rectification.

Application of Evidence-Based Strategies

To address the aforementioned safety concerns, several evidence-based strategies should be implemented. First, structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) have demonstrated effectiveness in improving handoff procedures and reducing communication errors. A study conducted at Tabanan Hospital indicated that SBAR implementation significantly enhanced nursing performance and patient safety during transitions of care (Mulfiyanti & Satriana, 2022).

Secondly, the implementation of continuous professional development, including simulation-based and scenario-specific training, can bridge competency gaps. Research has highlighted that a majority of medical equipment alerts are false, underscoring the need for regular in-service education on equipment usage and alarm interpretation to mitigate alarm fatigue (Shaoru et al., 2023).

Lastly, incorporating routine safety audits and feedback mechanisms can identify and resolve system-level gaps. Root-cause analysis and data-driven evaluations have proven effective in reinforcing safety culture and reducing the recurrence of sentinel events (Argyropoulos et al., 2024). These evidence-based approaches, when systematically applied, create a culture of continuous learning and improvement.

Safety Improvement Plan

Planned Actions for Each Root Cause/Contributing Factor

For the communication failures, standardized SBAR communication will be mandated during all patient handoffs to ensure clarity and consistency. To resolve training deficits, a comprehensive education plan will be introduced, incorporating onboarding and refresher courses focused on emergency procedures and equipment handling. For alarm fatigue, technical reviews will be conducted to fine-tune alarm settings and minimize desensitization to non-critical alerts.

New Policies and Professional Development Initiatives

New policies will formalize the use of SBAR across all departments. Concurrently, a structured training schedule will be developed, encompassing simulations, drills, and equipment use certifications. Alarm system management protocols will also be optimized through interdisciplinary collaboration. These initiatives will be reinforced by a strong culture of accountability, feedback, and continuous learning.

Goals and Timeline

The overarching goal is to enhance communication, reduce preventable errors, and improve clinical responsiveness. The SBAR protocol is scheduled for rollout within 1–2 months. Staff training initiatives will begin within three months and continue quarterly. Alarm optimization efforts will start within three months, with full implementation by six months. Desired outcomes include reduced sentinel events, improved team performance, and elevated patient safety metrics within a 6–12 month timeframe.

Existing Organizational Resources

Resources to Leverage

The organization can utilize existing expertise among senior staff for mentorship and hands-on training roles. The current electronic health record (EHR) system can be optimized to support structured communication and monitor safety metrics. Additionally, existing interprofessional teams and safety guidelines provide a solid foundation for implementing improvements.

Resources to Obtain

Investment in advanced training modules for SBAR communication and alarm management is essential. Equipment upgrades may be necessary to ensure alarms are reliable and user-friendly. Lastly, data analytics tools should be acquired to assess the effectiveness of interventions, track trends, and support decision-making.

References

Argyropoulos, C. D., Obasi, I. C., Akinwande, D. V., & Ile, C. M. (2024). The impact of interventions on health, safety and environment in the process industry. Heliyon, 10(1), e23604–e23604. https://www.sciencedirect.com/science/article/pii/S2405844023108127

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275