Capella FPX 4045 Assessment 2
Capella FPX 4045 Assessment 2
Name
Capella university
NURS-FPX4045 Nursing Informatics: Managing Health Information and Technology
Prof. Name
Date
Root-Cause Analysis and Safety Improvement Plan
1. Sentinel Event Analysis and Contributing Factors
A sentinel event refers to an unexpected occurrence involving death or serious physical or psychological injury, not related to the patient’s underlying condition. These incidents can significantly impact not only patients and their families but also the health care professionals involved. The core purpose of examining such events is to identify flaws in the care system and implement changes to prevent similar occurrences.
In this case, the event occurred in the Emergency Department (ED) due to a miscommunication during patient handoff. A critical septic patient did not receive timely care as essential information was omitted during shift transition. The patient’s condition deteriorated, resulting in an extended hospital stay and additional medical interventions. Family members experienced emotional distress, and the healthcare team faced increased workloads, reputational concerns, and the potential for disciplinary action.
Investigation into why the event occurred revealed several human, systemic, and cultural factors. The outgoing nurse, burdened by fatigue and an excessive workload, failed to communicate critical data effectively. There was a lack of structured communication tools, such as SBAR, and documentation was incomplete. Moreover, the hospital lacked a robust safety culture and leadership oversight. Cultural diversity and varying communication styles among staff also influenced the event. Physical layout challenges, understaffing, and malfunctioning equipment further complicated care delivery, as did unclear hospital policies and a lack of regular monitoring or surveillance.
2. Breakdown of Factors and Root Causes
To understand the event comprehensively, various components were analyzed. It was evident that the hospital’s SBAR protocol was not consistently used. The outgoing nurse failed to conduct a bedside handoff or double-check care plans. The incoming nurse did not seek clarification, assuming the information was complete. Vital signs were inadequately monitored, and alarms went unanswered due to alarm fatigue. Staff involved included the two nurses and a physician whose medication orders were not effectively communicated. Supervisors failed to reinforce training or audit the handoff process.
Furthermore, policies were not followed due to lack of accessibility and clarity. Staff reported difficulties locating updated guidelines, which led to inconsistencies. These lapses were compounded by environmental issues such as distant nurse stations and faulty equipment. Training gaps were also evident, particularly in handoff communication and patient monitoring. Collectively, these breakdowns highlight an organizational failure to enforce safety protocols and support staff adequately.
3. Strategies for Improvement and Preventive Measures
To prevent recurrence of such events, several systemic changes and quality improvements must be implemented. Evidence-based best practices like structured SBAR communication should be standardized. Studies, such as the one by Mulfiyanti and Satriana (2022), have demonstrated significant improvements in handoff efficiency and healthcare quality after implementing SBAR. Additionally, regular simulation-based training can enhance staff competency in emergency responses.
To address alarm fatigue, improved alarm management systems and prioritization protocols are needed. Introducing fail-safe mechanisms such as automatic alerts for critical values and consistent audits will support early detection of patient deterioration. Educational programs should be mandated regularly, focusing on emergency protocols and communication skills. Finally, fostering a culture that encourages transparent reporting of errors without fear of punishment can lead to continual learning and safer practices.
Tabular Summary of Root Causes and Contributing Factors
| Root Cause / Contributing Factor | Category | Code |
|---|---|---|
| Breakdown in communication between care team | Human Factor – Communication | HF-C |
| Insufficient training on updated protocols | Human Factor – Training | HF-T |
| Malfunctioning equipment causing delayed intervention | Environment / Equipment | E |
| Staff fatigue due to poor scheduling | Human Factor – Fatigue | HF-F/S |
| Failure to follow safety protocols | Rules / Policies / Procedures | R |
| Organizational barriers to effective teamwork | Barriers | B |
Evidence-Based Strategy Table
| Strategy | Objective | Supporting Evidence |
|---|---|---|
| SBAR Handoff Protocol | Standardize communication during patient handoffs | Mulfiyanti & Satriana, 2022 |
| Simulation-Based Emergency Training | Improve staff response to critical incidents | Mulfiyanti & Satriana, 2022; AHRQ, 2020 |
| Alarm Management Systems | Reduce alarm fatigue and increase responsiveness | AHRQ, 2020 |
| Continuous Education and Refresher Courses | Maintain up-to-date knowledge on medication protocols | WHO, 2021 |
| Structured Reporting and Feedback Culture | Encourage non-punitive incident reporting | The Joint Commission, 2019 |
References
Agency for Healthcare Research and Quality. (2020). TeamSTEPPS®: Strategies and tools to enhance performance and patient safety. https://www.ahrq.gov/teamstepps/index.html
Mulfiyanti, R., & Satriana, I. W. (2022). The effect of SBAR communication on handoff quality at Tabanan Hospital. Griyatama Nursing Journal, 12(3), 150–156.
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
The Joint Commission. (2019). Sentinel Event Policy and Procedures. https://www.jointcommission.org/sentinel_event_policy
World Health Organization. (2021). Patient safety: Global action on patient safety. https://www.who.int/publications/i/item/9789240025710