Capella FPX 4035 Assessment 2

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 Sentinel Event and What Happened

Sentinel events refer to unexpected occurrences in healthcare settings that lead to severe patient harm and are not directly caused by the natural progression of the patient’s medical condition. These events often lead to emotional and operational strain for both patients and healthcare providers. The ultimate objective of analyzing sentinel events is to uncover both immediate and root causes to enhance patient safety systems and prevent future occurrences.

In this case, a sentinel event occurred within the Emergency Department (ED) due to the breakdown of proper communication during a patient handoff. A septic patient’s condition deteriorated because essential clinical information was omitted by the outgoing nurse, and there was inadequate documentation. As a result, treatment was delayed, extending the patient’s hospital stay and necessitating additional interventions. This affected the patient’s well-being, caused stress to the family, and increased workload and accountability concerns among staff. The hospital also faced reputational damage, increased costs, and scrutiny from regulatory bodies.

Analysis of Why the Event Happened

Human Factors

Staff fatigue, high patient volumes, and lack of training on standardized handoff methods contributed significantly. The outgoing nurse, under stress and time constraints, provided a partial verbal update without using structured formats like SBAR, increasing the likelihood of omissions.

System Factors

A lack of electronic handoff tools, staff shortages, and a disorganized work environment in the ED created further challenges. These systemic inefficiencies impeded effective transitions of care.

Organizational Culture

The absence of a robust safety culture, weak leadership support, and minimal oversight regarding communication practices reduced accountability. Supervisory staff failed to enforce or monitor compliance with standardized handoff protocols.

Societal and Cultural Aspects

Differences in cultural and linguistic backgrounds among staff may have led to misinterpretations and unclear communication during the handoff process, further impacting patient safety.

Protocol Deviations and Documentation Gaps

Upon review, it was evident that the SBAR protocol was not followed during the handoff. The outgoing nurse omitted crucial patient information without structured verification, while the receiving nurse failed to ask clarifying questions. Additionally, bedside handoff procedures were skipped. Medical documentation lacked essential updates about the patient’s condition and care needs, leading to delayed interventions and oversight in medication administration.

Involvement of Staff and Leadership

The central figures involved were the outgoing and incoming nurses, who both failed to ensure comprehensive communication. A physician had also issued new medication orders that were not adequately conveyed. Leadership figures, such as the charge nurse and nurse managers, failed to enforce training on handoff protocols or monitor transitions effectively. Their oversight gaps contributed to the event.

Communication Breakdown

There was a clear lapse in interdisciplinary communication. The nursing and medical teams failed to coordinate properly, particularly concerning new medication orders. Patient-provider communication also suffered, as the patient was not informed of updates in the treatment plan, leading to confusion and reduced trust in care delivery.

Contributing Environmental and Staffing Factors

The ED layout, with remote nursing stations and malfunctioning equipment, hindered prompt information exchange. Suboptimal staffing levels left nurses overwhelmed, compromising their ability to adhere to care protocols. Although staff were generally competent, insufficient training on handoff protocols and outdated knowledge regarding medications contributed to the breakdown.

Policy Clarity and Compliance

Deviation from established handoff policies occurred, largely due to ambiguous and poorly accessible protocols. Some staff reported difficulty locating the latest guidelines, leading to inconsistent care transitions and increased risk of error.

Monitoring and Surveillance Failures

Vital signs were not monitored consistently during critical periods. Additionally, alarm fatigue was evident; frequent alarms led to desensitization, and significant alerts went unnoticed. These failures exacerbated the patient’s condition and delayed intervention.

Lessons Learned and Recommendations

Improving communication standards, enhancing training on early warning signs, and fostering a culture of safety are essential measures. Regular simulations, policy reinforcement, and accountability systems can improve future outcomes. Additionally, installing fail-safes for abnormal vital signs and conducting routine safety audits will help prevent similar events.

Enhancing Patient Safety

To bolster patient safety, institutions should focus on proactive risk mitigation. This includes continuous staff education, structured communication tools, and a non-punitive environment for incident reporting. Encouraging transparency and providing regular feedback loops are vital steps for long-term improvement.

Table 1: Root Causes and Contributing Factors

Codes: 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

Evidence-based strategies are essential in preventing sentinel events, especially those caused by miscommunication and technological issues. According to research conducted in Tabanan Hospital, structured communication tools like SBAR significantly improve handoff quality and overall patient safety (Mulfiyanti & Satriana, 2022).

Furthermore, ongoing simulation training and competency evaluations can mitigate risks related to alarm fatigue and monitoring errors. Studies have shown that up to 99% of alarms may be false, leading to desensitization (Shaoru et al., 2023). Training focused on alarm management and emergency response helps ensure staff respond appropriately in high-risk situations.

Instituting quality improvement frameworks such as Plan-Do-Study-Act (PDSA) cycles, safety audits, and continuous feedback mechanisms reinforces accountability and systemic enhancements. A consistent focus on staff development, technology upgrades, and leadership engagement can create a sustainable safety culture.

Safety Improvement Plan

Future Preventive Measures to Avoid Reoccurrence

To prevent the recurrence of previously identified safety issues, a structured set of interventions will be implemented, targeting the underlying root causes. Emphasis will be placed on enhancing communication, improving staff training, and minimizing alarm fatigue. Structured communication techniques, such as SBAR (Situation, Background, Assessment, Recommendation), will be systematically introduced during all patient handoffs to ensure clarity and completeness of information. Additionally, a rigorous training regimen will be developed for both newly recruited staff and existing employees to strengthen their competencies in emergency protocols and equipment management. Alarm fatigue will be addressed by re-evaluating alarm settings to eliminate unnecessary alerts and ensure prompt responses to critical signals.

Action Plan Table

E = Eliminate; C = Control; A = Accept

Policies, Processes, and Professional Development

Implementation of New Standards

To correct systemic issues, several initiatives will be introduced, including formalized communication models and professional development programs. The SBAR framework will become standard practice across all care transitions to enhance clarity and accountability during handoffs. Regular educational sessions will reinforce this protocol. Simultaneously, new staff members will undergo competency-based onboarding training, and current staff will participate in periodic refresher courses covering essential topics like emergency response, proper equipment use, and patient safety. Addressing alarm fatigue involves conducting a facility-wide review of alarm systems, adjusting thresholds and frequency to ensure only essential alarms activate. These process changes are designed to foster a proactive safety culture and reduce preventable errors, consistent with evidence-based healthcare practices.

Goals, Outcomes, and Timeline

Expected Results and Implementation Timeline

The overarching goal of the action plan is to elevate patient safety and operational performance by improving communication, enhancing staff competency, and minimizing alarm fatigue. Specific outcomes include a decrease in adverse safety events, better care continuity, and higher staff confidence and engagement.

Implementation Timeline Table

It is anticipated that measurable improvements in patient safety and workflow efficiency will become evident within 6 to 12 months of initiating the plan.

Organizational Resources

Leveraging and Acquiring Resources

Utilizing Existing Resources

To successfully implement the safety improvement initiatives, several existing organizational assets will be utilized:

• Skilled Staff: Experienced personnel will be designated to mentor, train, and lead process implementations.
• Digital Infrastructure: The current Electronic Health Record (EHR) system will be adapted to support new communication protocols and track safety metrics.
• Policy Framework: Existing safety guidelines will serve as a foundation for refining and expanding patient safety measures.
• Interdisciplinary Teams: Collaboration across nursing, pharmacy, IT, and physician departments will streamline communication and enhance teamwork.

Additional Resources Required

For effective execution, certain supplementary resources will need to be secured:

• Training Programs: Investment in customized SBAR communication and alarm management training tools.
• Technology Upgrades: Procurement of advanced patient monitoring systems and alarm technologies to mitigate fatigue.
• Data Analysis Tools: Acquisition of analytical software to monitor safety data and evaluate the impact of implemented changes.

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

Capella FPX 4035 Assessment 2

Shaoru, C., Zhi, H., Wu, S., Ruxin, J., Huiyi, Z., Zhang, H., & Zhang, H. (2023). Determinants of medical equipment alarm fatigue in practicing nurses: A systematic review. SAGE Open Nursing, 9(9). https://doi.org/10.1177/23779608231207227