Capella 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

Root-cause analysis (RCA) can help healthcare organizations identify why a patient safety event occurred and determine which system, communication, staffing, training, and environmental factors contributed to it. In the emergency department (ED) scenario described here, an incomplete nursing handoff contributed to delays in recognizing and responding to a patient’s worsening condition. A comprehensive safety improvement plan should therefore address communication failures while also strengthening staff training, monitoring systems, staffing practices, policy adherence, and organizational oversight.

Understanding the Patient Safety Incident

A sentinel event is a serious patient safety event that can result in significant harm and requires an organization to examine the underlying causes. Rather than focusing only on the individual who made an error, RCA examines how multiple conditions within the healthcare system may have contributed to the event.

In this case, a patient arrived in the ED with septic shock and experienced critical delays in treatment following an incomplete shift handoff. The outgoing nurse did not communicate important clinical information, while the available documentation did not adequately capture the patient’s condition and care needs. As a result, the patient’s condition deteriorated, requiring additional interventions and contributing to a prolonged hospitalization.

The incident also affected healthcare professionals involved in the patient’s care and revealed weaknesses in communication, documentation, staffing, monitoring, and organizational oversight. These findings demonstrate why patient safety investigations should consider both individual actions and broader system conditions.

Contributing Factors and Root Causes

The RCA identified several interconnected factors rather than a single cause. Human factors included nurse fatigue, inconsistent communication, and insufficient training in structured handoff techniques. Relying primarily on verbal communication without a reliable written or electronic record increased the possibility that critical information would be omitted or misunderstood.

Environmental and organizational conditions also contributed. The ED layout made communication and patient observation more difficult, while malfunctioning equipment created additional safety concerns. Staffing shortages increased workload and contributed to workflow disruptions. These conditions can make it more difficult for clinicians to consistently follow established safety procedures, particularly during periods of high patient volume.

Differences in language and communication styles among members of a diverse healthcare workforce may also create additional communication challenges when information is transferred between clinicians. For this reason, standardized communication processes can provide a consistent framework for exchanging essential patient information.

Deviation From Standardized Handoff Practices

The SBAR framework—Situation, Background, Assessment, and Recommendation—is designed to organize clinical communication and help healthcare professionals convey important information consistently. In the incident described, SBAR was not effectively incorporated into the handoff process.

The outgoing nurse provided an incomplete verbal report, and the incoming nurse did not obtain clarification about missing information. Documentation also failed to adequately communicate important changes in the patient’s condition and treatment plan.

A standardized handoff process should therefore include both verbal communication and appropriate documentation. Using a consistent structure can reduce omissions and provide receiving clinicians with a clearer understanding of the patient’s current status, recent changes, and immediate care requirements.

Roles and Responsibilities of the Healthcare Team

Several healthcare professionals had responsibilities relevant to the event. The outgoing nurse was responsible for communicating the patient’s condition and current care needs during handoff. The incoming nurse was responsible for reviewing the information received and clarifying uncertainties.

The attending physician also modified treatment plans, but the changes were not consistently communicated to all members of the care team. The charge nurse did not adequately reinforce compliance with the established handoff process. At the organizational level, limited managerial monitoring meant that adherence to communication policies and training requirements was not consistently evaluated.

These findings demonstrate that patient safety is an interprofessional responsibility. Effective communication requires participation from nurses, physicians, charge nurses, managers, and other members of the healthcare team.

Communication Breakdown

Communication failures were a central contributor to the incident. Important information concerning the patient’s deteriorating condition and changes in treatment was not consistently shared among nurses and physicians. The lack of reliable communication increased the possibility of delayed recognition and delayed intervention.

Patient communication was also affected. When patients are clinically able to participate, providing understandable information about changes in their condition and treatment can support shared decision-making and patient engagement.

A reliable communication process should therefore ensure that critical information is transferred:

Between outgoing and incoming nurses
Between nurses and physicians
During changes in treatment plans
During transfers between care areas
Through appropriate clinical documentation
To the patient and family when appropriate

Environmental and Staffing Challenges

The physical environment of the ED created additional barriers to safe care. Separate nursing stations made direct communication and patient observation more difficult, while malfunctioning equipment increased the risk of missed clinical information.

Chronic understaffing further increased workload and contributed to missed procedures and reduced opportunities for thorough communication. Although staff members may have possessed appropriate general clinical knowledge, additional preparation may have been needed for high-risk situations involving rapidly deteriorating patients and complex medication regimens.

Staffing and workload should therefore be considered part of the patient safety analysis rather than treating communication failures as isolated individual mistakes.

Organizational Policy and Monitoring Gaps

Existing handoff and medication-safety policies were not consistently followed. Policies that are difficult to access, overly complicated, or insufficiently reinforced may contribute to variation in practice between shifts.

Regular audits can help organizations determine whether safety procedures are actually being followed in daily practice. Leadership should monitor compliance, provide feedback, identify recurring barriers, and revise processes when necessary.

Another important concern was inadequate monitoring of the patient’s vital signs during critical periods. Alarm fatigue can occur when clinicians are exposed to frequent alerts, including alerts that are nonactionable or clinically insignificant. Over time, excessive alarms can make it more difficult for staff to recognize important warnings.

Evidence-Based Patient Safety Interventions

Evidence-based interventions can address several of the contributing factors identified through RCA. Structured communication is particularly important during transitions of care because it creates a predictable process for transferring essential clinical information. Research by Mulfiyanti and Satriana (2022) examined the relationship between SBAR communication and nursing handover implementation in relation to patient safety.

Simulation-based education can also help clinicians practice responses to emergencies and rapidly changing clinical situations. Rather than relying solely on classroom instruction, simulation allows staff to rehearse communication, assessment, prioritization, and escalation in realistic scenarios.

Alarm management is another important intervention. Organizations can review alarm settings, reduce unnecessary alerts, maintain equipment appropriately, and train staff to recognize and respond to clinically significant alarms. Evidence concerning alarm fatigue supports systematic approaches to reducing unnecessary alarm exposure.

Routine audits and feedback can further reinforce safety practices. Monitoring compliance with handoff standards, reviewing incident trends, and providing constructive feedback can help organizations identify weaknesses before they contribute to serious harm.

Root Causes and Contributing Factors

Factor Category	Identified Issue	Classification
Communication breakdown	Critical patient information was not transferred effectively during handoff	HF-C: Human Factor—Communication
Training deficiencies	Staff education regarding updated procedures and handoff standards was insufficient	HF-T: Human Factor—Training
Equipment malfunction	Inoperable or unreliable alarms contributed to delayed recognition of deterioration	E: Environment/Equipment
Staff fatigue	Long shifts and scheduling problems reduced alertness and cognitive performance	HF-F/S: Human Factor—Fatigue/Scheduling
Policy non-adherence	Established safety procedures were inconsistently applied	R: Rules/Policies/Procedures
Communication infrastructure	Digital and structured handoff resources were insufficient	B: Barriers

Application of Evidence-Based Strategies

Intervention	Strategy	Supporting Evidence
Structured communication	Use SBAR to organize and standardize handoff reports	Mulfiyanti & Satriana, 2022
Simulation-based training	Prepare staff for emergencies and complex clinical situations	Shaoru et al., 2023
Alarm optimization	Reduce unnecessary alerts and improve alarm recognition and response	Shaoru et al., 2023
Routine audits and feedback	Identify procedural gaps and support continuous safety improvement	Argyropoulos et al., 2024

Safety Improvement Plan

A successful safety improvement plan should connect each identified root cause with a specific intervention, responsible leadership, and measurable implementation timeline. The objective is not simply to introduce new policies but to ensure that the changes become part of routine clinical practice.

Root Cause	Planned Action	Proposed Timeline
Communication failures	Require SBAR for all applicable transitions of care and reinforce closed-loop communication	1–2 months
Training gaps	Introduce onboarding education, simulation exercises, and quarterly refresher training	Begin within 3 months
Alarm desensitization	Review and calibrate alarm systems and provide alarm-response education	3–6 months
Policy non-adherence	Develop simplified, accessible versions of critical safety protocols	Within 3 months

Existing Organizational Resources and Additional Needs

Healthcare organizations can build on resources that are already available. Experienced senior nurses can provide mentorship, while existing electronic health records can support documentation and communication tracking. Interprofessional safety teams can also assist with monitoring and quality-improvement initiatives.

Additional resources may be necessary to sustain the improvements. These may include advanced SBAR and alarm-management training, upgraded patient-monitoring equipment, real-time data analytics, and dedicated funding for staff education and safety-system improvements.

Measuring the Effectiveness of the Safety Plan

Implementation should be followed by measurable evaluation. Leadership can monitor handoff compliance, documentation completeness, response to critical alarms, staff participation in training, and the frequency of communication-related safety events.

The organization can use audit findings and staff feedback to determine whether interventions are working as intended. When problems continue to occur, the RCA process should be revisited rather than assuming that staff education alone will resolve the issue.

A non-punitive reporting environment is particularly important. Staff should be encouraged to report near misses, equipment problems, communication barriers, and unsafe conditions without fear that reporting will automatically result in punishment. This approach can provide leadership with information needed to identify system weaknesses and support continuous improvement.

Conclusion

Root-cause analysis provides a structured way to understand how communication, staffing, training, equipment, policies, and organizational culture can interact to create patient safety risks. In this ED incident, the incomplete handoff was an immediate contributor, but the broader analysis identified multiple system-level conditions that also required attention. Standardized SBAR communication, simulation-based education, improved alarm management, accessible policies, routine auditing, and stronger leadership oversight can create multiple layers of protection against similar events. Sustainable patient safety improvement requires organizations to evaluate both individual practices and the systems in which healthcare professionals work.

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. 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, 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275