NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
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Capella university
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
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Root-Cause Analysis and Safety Improvement Plan
A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, not primarily related to the natural progression of a patient’s illness or condition. These events are deeply distressing for both patients and healthcare providers and serve as critical reminders of the importance of robust safety systems. The objective of conducting a thorough root-cause analysis (RCA) is to uncover not only immediate causes but also underlying systemic flaws that may contribute to these adverse outcomes. By identifying these factors, organizations can implement sustainable changes to prevent recurrence and enhance patient safety.
Understanding What Happened
In this particular case, the sentinel event took place in the Emergency Department (ED), where a miscommunication during a patient handoff led to a delay in treatment. A septic patient’s deteriorating condition was not clearly communicated by the outgoing nurse due to omissions in critical details and insufficient documentation. As a result, the patient’s condition worsened, leading to an extended hospital stay and additional medical interventions. The event affected multiple stakeholders. The patient experienced health deterioration and psychological distress; family members faced emotional stress; and healthcare providers endured increased workloads and potential disciplinary scrutiny. The institution faced regulatory reviews, financial repercussions, and a tarnished reputation.
Several factors contributed to this event. Human elements such as fatigue, high workload, and inadequate training led to incomplete verbal handoffs. Systemic flaws, including inefficient workflow and lack of structured electronic tools, compounded the problem. The organizational culture lacked a robust emphasis on safety, leadership oversight, and accountability. Additionally, cultural and language differences among staff affected the clarity of communication. These interconnected factors underscore the importance of addressing both human and structural components in patient safety initiatives.
Deviation from Protocols and Breakdown in Communication
The standardized SBAR (Situation, Background, Assessment, Recommendation) protocol was not adhered to during the handoff. Critical patient data was omitted, and there was no structured process to verify understanding between staff. Documentation in medical records and nursing notes lacked key details such as pending care needs and medication administration. Consequently, critical interventions were delayed.
The event also exposed weaknesses in interdisciplinary and patient-provider communication. Nurses failed to exchange vital updates about new medication orders. The patient was inadequately informed about their evolving care plan, potentially compromising their trust and engagement in treatment. These lapses in communication underscore the need for structured protocols and training.
Contributing Factors and Policy Gaps
Environmental constraints, such as poorly placed nursing stations and malfunctioning devices, hindered effective information flow. Staffing shortages led to nurse fatigue and decreased attention to protocol adherence. While staff were generally competent, gaps in training—especially around updated handoff procedures—were evident. Policy compliance issues also played a significant role. While protocols existed, they were not effectively communicated or enforced. Many staff members reported difficulty accessing current guidelines, leading to inconsistencies in practice.
Vital signs monitoring during critical periods was insufficient. Nurses failed to notice changes in the patient’s condition in real time. Furthermore, alarm fatigue—a common issue in high-volume units—resulted in missed alerts. These system failures compounded the risks already introduced by human and procedural lapses.
Learning from the Incident and Enhancing Patient Safety
This incident offers several important lessons. Systemic interventions must include strengthening communication strategies, particularly by reinforcing SBAR and bedside handoff procedures. Training should be updated regularly and include simulation of high-risk scenarios to ensure staff are prepared for emergencies. A cultural shift is also needed, with a focus on safety, accountability, and open dialogue.
Preventive strategies include upgrading monitoring systems, refining alarm protocols, and introducing checklists for critical transitions. Frequent audits and feedback loops should be implemented to identify risks proactively. A non-punitive reporting culture should be cultivated to encourage transparency and continuous learning. These measures can help mitigate risks and elevate the standard of patient care.
Root Cause and Contributing Factors Table
| Root Cause / Contributing Factor | Category | Code |
|---|---|---|
| Breakdown in communication between the care team, leading to misinterpretation of patient condition | Human Factor – Communication | HF-C |
| Insufficient training on updated protocols, causing staff to miss critical care changes | Human Factor – Training | HF-T |
| Malfunctioning equipment led to missed warning signs and delayed intervention | Environment / Equipment | E |
| Staff fatigue due to poor scheduling affected attention and decision-making | Human Factor – Fatigue/Scheduling | HF-F/S |
| Failure to follow safety protocols resulted in missed interventions | Rules / Policies / Procedures | R |
| Organizational barriers, including poor communication channels, hindered effective teamwork | Barriers | B |
Code Key: HF-C = Human Factor – Communication HF-T = Human Factor – Training HF-F/S = Human Factor – Fatigue/Scheduling E = Environment / Equipment R = Rules / Policies / Procedures B = Barriers
Application of Evidence-Based Strategies
Addressing sentinel events requires the implementation of evidence-based strategies that target both systemic and human factors. One of the most effective approaches involves the adoption of structured communication tools such as SBAR. Research conducted in the Griyatama Inpatient Room at Tabanan Hospital demonstrated that consistent use of SBAR significantly improves communication effectiveness, particularly during handoffs and emergency transitions (Putra et al., 2022).
Improving alarm management systems is also critical. Alarm fatigue is a well-documented contributor to missed interventions, and literature suggests that prioritizing critical alarms and reducing unnecessary alerts can improve staff responsiveness (Cvach, 2012). Incorporating automated alert systems for abnormal vital signs can further reduce oversight and enhance timely interventions.
Another key strategy is the implementation of routine simulation training and refresher courses. These sessions reinforce proper handoff procedures, ensure knowledge of updated protocols, and provide staff with hands-on experience in managing complex cases. Encouraging a culture of open reporting, supported by leadership, can transform adverse events into opportunities for learning and systemic improvement.
References
Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation & Technology, 46(4), 268–277. https://doi.org/10.2345/0899-8205-46.4.268
Putra, A. A., Wardani, E. Y., & Sari, K. (2022). Implementation of SBAR communication method to improve handover effectiveness in inpatient care. Journal of Nursing Practice, 6(1), 23–29. https://doi.org/10.30994/jnp.v6i1.199
The Joint Commission. (2023). Sentinel Event Policy and Procedures. Retrieved from https://www.jointcommission.org/sentinel_event_policy
