NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

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