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

Understanding What Happened

Sentinel events are unexpected, serious patient safety incidents unrelated to a patient’s existing condition, highlighting breakdowns in care processes. In this scenario, such an event took place in the Emergency Department when critical information about a patient with sepsis was not communicated during shift change. As a result, initiation of appropriate therapy was delayed, patient outcomes deteriorated, and undue stress was placed on both the patient’s family and the care team. The hospital’s reputation also suffered due to this lapse.

Contributing factors existed at multiple levels. From an individual standpoint, nurse exhaustion and insufficient structured guidance during handoffs were key issues. Reliance on informal verbal briefings, without thorough documentation, increased the likelihood of omissions. At the system level, workflow inefficiencies, absence of digital handoff platforms, and high patient volumes in the ED exacerbated communication gaps. Organizationally, leadership did not reinforce standardized handoff procedures, and a culture of safety had not been fully established. Moreover, linguistic diversity among staff introduced additional barriers to clear exchanges.

Analyzing the Breakdown

Investigation revealed the shift-to-shift report deviated from the SBAR (Situation, Background, Assessment, Recommendation) framework, and there was no mechanism to verify that the incoming nurse had understood all critical details. Records in the patient’s chart and nursing notes were incomplete, causing further delays. The care team included the outgoing and incoming nurses as well as a physician whose treatment orders were not effectively transmitted.

Interdisciplinary communication also faltered: essential updates about medications and care priorities were lost, and the patient remained unaware of changes to their treatment plan. Environmental issues—such as distant nursing stations, malfunctioning monitoring devices, and short staffing—created conditions ripe for error. Staff had limited training on proper handoff procedures and on the use of emergency equipment. Although hospital policies existed, they were neither sufficiently disseminated nor easily accessible to front-line personnel.

Toward Safer Outcomes

The sentinel event underscored the absence of reliable monitoring systems and a tendency to ignore frequent, non-actionable alarms, delaying recognition of patient deterioration. To address these issues, structured communication protocols like SBAR must be adopted to standardize information transfer. Evidence supports that such tools enhance handoff clarity and reduce errors (Mulfiyanti & Satriana, 2022).

Ongoing, simulation-based workshops and competency assessments should be implemented to ensure all staff are proficient in equipment operation and alarm response (Shaoru, Wang, & Huan, 2023). Regular safety rounds, targeted audits, and a non-punitive error-reporting culture will foster continuous learning. Establishing feedback loops and open communication channels encourages accountability and systemic improvement.

Summary of Root Causes and Improvement Actions

Root Cause / Contributing Factor	Category	Proposed Action	E / C / A
Communication gaps	Human – Communication	Adopt SBAR for handoffs, include a read-back verification step	E
Limited staff training	Human – Education	Implement regular, scenario-based simulations and refresher sessions	E / C
Nurse fatigue and high workload	Human – Scheduling	Optimize staffing models and shift rotations to prevent burnout	C
Equipment failures	Environment – Technology	Enhance maintenance schedules and upgrade monitoring devices	E
Policy non-compliance	Organizational – Procedures	Digitize protocols and mandate periodic policy review trainings	C
Incomplete documentation	System – Workflow	Introduce electronic checklists with supervisory audit checkpoints	C

Legend: E = Eliminate causes; C = Control through processes; A = Accept with minimal action.

Application of Evidence-Based Strategies

Using structured communication tools like SBAR during transitions of care has been shown to significantly lower error rates in clinical settings. Mulfiyanti and Satriana (2022) demonstrated improved accuracy and consistency in nurse handoffs. Additionally, Shaoru et al. (2023) highlighted that reducing false or non-critical alarms through alarm optimization, coupled with targeted training, enhances staff responsiveness to true emergencies.

Regular, systematic audits and feedback loops are crucial for identifying protocol deviations and driving quality improvement. Argyropoulos, Johnson, and Rivera (2024) recommend using root-cause analyses routinely to uncover latent system flaws and reinforce patient safety measures.

Safety Improvement Plan

Communication Standardization: Mandate SBAR use for all handoffs with confirmation of information accuracy.
Comprehensive Training: Develop a formalized curriculum of simulation exercises to maintain proficiency in equipment use and handoff methodology.
Alarm Management: Adjust alarm thresholds to reduce false alerts; provide targeted training on prioritizing critical alarms.
Policy Accessibility: Upgrade the policy repository to an electronic platform accessible at each workstation.
Staffing Optimization: Conduct workload analyses and redesign schedules to distribute patient assignments evenly and decrease fatigue.

Implementing these targeted interventions within a supportive, learning-oriented culture can markedly decrease sentinel events and advance patient safety outcomes.

References

Argyropoulos, D., Johnson, L., & Rivera, J. (2024). Continuous improvement through root-cause analysis in hospital safety systems. Journal of Healthcare Risk Management, 44(1), 12–21. https://doi.org/10.1002/jhrm.2198