Student Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Root-Cause Analysis and Safety Improvement Plan
Sentinel events are unforeseen patient safety incidents that result in serious physical or psychological injury or even death, and are not connected to the natural progression of an illness. These events are distressing not only to the patients but also to healthcare professionals who are directly involved. The primary objective following such events is to engage in deep analysis, identify causes, and establish mechanisms to prevent recurrence.
Root-cause analysis (RCA) serves as a structured method to identify not only the direct reasons behind such events but also the underlying systemic flaws that may have contributed. This approach ensures healthcare organizations learn from errors, enhance processes, and protect patient welfare.
Understanding What Happened
What Happened?
An adverse event occurred in the Emergency Department (ED) due to an improper handoff between medical personnel. A critical septic patient’s condition was not communicated effectively during the nurse shift change, where vital information was omitted and documentation was incomplete. The result was delayed treatment, deterioration in the patient’s health, and an extended hospital stay requiring additional interventions.
This incident significantly affected all stakeholders. The patient’s health worsened, while their family experienced emotional turmoil. The care team faced increased workloads, reputational risk, and administrative repercussions. Consequently, the healthcare facility was prompted to reconsider and revise its handoff protocols, acknowledging the broader implications on quality care and regulatory compliance.
Why Did It Happen?
A range of factors played a role in the sentinel event. Human elements included nurse fatigue, lack of standardized training, and an overreliance on verbal communication. The system itself was flawed—there was a lack of effective workflow processes, limited access to electronic handoff tools, and a disorganized work environment. Additionally, the hospital’s culture lacked adequate support for safety protocols and leadership accountability. Differences in language and communication norms also contributed to misunderstandings among a diverse staff.
Was There a Deviation from Standards?
There was indeed a significant deviation from standard procedures. The SBAR (Situation, Background, Assessment, Recommendation) communication method, which the hospital had in place for shift handoffs, was not fully executed. The outgoing nurse gave a partial verbal report without full documentation, and the incoming nurse accepted the handoff without seeking clarification. Furthermore, bedside handoffs and verification processes were absent, and essential patient care elements were undocumented, leading to missed treatments.
Analysis of Contributing Factors
Who Was Involved?
The incident involved both outgoing and incoming nurses, where the former failed to relay all essential information, and the latter did not verify the handoff. A physician who updated the medication regimen also played a part, as those orders were not properly communicated. Supervisors, such as the charge nurse and unit manager, failed to ensure protocol compliance and had not emphasized communication training.
Was There a Communication Breakdown?
There was a clear communication breakdown between interdisciplinary teams. Nurses did not exchange critical information, and physician orders were not properly shared. Moreover, the patient was not adequately informed of changes in their treatment plan, creating confusion and potential mistrust.
What Were the Contributing Factors?
The physical environment, such as distant nursing stations and malfunctioning equipment, hindered real-time communication. The department was understaffed, leading to overwhelming workloads and gaps in care. Training was insufficient—staff lacked refresher courses on communication protocols and proper use of equipment, increasing the likelihood of error.
Did Organizational Policies Play a Role?
Policy adherence was suboptimal. Although procedures for handoffs and medication protocols existed, they were poorly communicated and inconsistently applied. Many staff members expressed confusion over where to locate updated guidelines, reducing their effectiveness and undermining compliance.
Was There a Monitoring Failure?
Vital signs were inadequately monitored, with essential changes in patient condition going undocumented. Alarm fatigue further contributed, as frequent non-urgent alerts led staff to ignore potentially life-saving signals. This delay in response compromised the patient’s safety and prolonged their recovery.
Table: Root Causes and Contributing Factors
| Root Cause | Contributing Factors | Category |
|---|---|---|
| Communication breakdown between staff led to missed updates on patient status | Lack of standardized handoff and failure to verify medication or treatment changes | HF-C (Human Factor – Communication) |
| Insufficient training on updated protocols and tools | Outdated training methods and lack of simulation exercises | HF-T (Human Factor – Training) |
| Fatigue due to excessive workload and poor scheduling | Understaffing during critical hours and high task volume | HF-F/S (Human Factor – Fatigue/Scheduling) |
| Inadequate alarm response due to desensitization | Frequent false alerts led to missed critical alarms | E (Environment/Equipment) |
| Organizational issues hampered information flow | Lack of protocol audits and weak leadership support | B (Barriers) |
Application of Evidence-Based Strategies
Evidence-based approaches are essential for improving safety in healthcare settings. One proven strategy is the implementation of SBAR communication, which promotes structured and effective handoffs. A study by Mulfiyanti and Satriana (2022) demonstrated that using SBAR in inpatient settings significantly improved the accuracy of patient transitions and overall nursing care quality.
To address training deficiencies, simulation-based learning and continuous education have shown promise. Shaoru et al. (2023) emphasized that many medical alerts are false positives and require staff training on identifying legitimate warnings. Ongoing workshops on alarm system usage and emergency protocols are vital for maintaining preparedness.
Systematic safety audits and feedback mechanisms ensure accountability and foster a learning environment. According to Argyropoulos et al. (2024), regular root-cause analysis and the application of data-driven insights help organizations improve system weaknesses and reduce sentinel event recurrence.
Strategy Implementation
Applying these strategies can transform healthcare delivery. The SBAR model should be standardized across all units for every patient handoff. Simulation-based learning programs need to be embedded into staff development schedules. Alarm management protocols must be reviewed to ensure meaningful alerts prompt timely responses.
Regular audits and open feedback sessions can reinforce safe practices, allowing staff to share concerns and contribute to quality improvements. These changes not only prevent harm but also build a proactive safety culture centered on accountability, collaboration, and continuous improvement.
Safety Improvement Plan
Action Plan for Preventing Recurrence
| Issue | Action | Type |
|---|---|---|
| Communication Breakdown | Implement SBAR for all shift handoffs with mandatory documentation and verification steps | E |
| Inadequate Training | Establish regular in-service training and simulation drills for equipment and emergency response | E/C |
| Alarm Fatigue | Optimize alarm system thresholds to reduce false alerts and enhance staff responsiveness | E |
New Policies and Professional Development
To tackle the identified issues, new hospital-wide policies will be enacted. First, a comprehensive SBAR protocol will be enforced, accompanied by visual checklists for handoffs. Orientation programs for new staff will include mandatory communication workshops. Additionally, monthly simulation labs will offer staff real-world practice in handling medical devices and emergency protocols.
Technology upgrades will address equipment malfunctions and alarm sensitivity. Leadership will also implement bi-weekly audits to assess protocol adherence. These efforts aim to eliminate ambiguity, strengthen competency, and reinforce a safety-first culture.
References
Argyropoulos, S. K., O’Connor, P., Taylor, M., & Moss, R. (2024). Data-driven safety improvements in clinical care: A systemic approach to root cause analysis. Journal of Healthcare Quality Research, 36(2), 123–131. https://doi.org/10.1016/j.jhqr.2023.10.005
Mulfiyanti, E., & Satriana, S. (2022). Effectiveness of SBAR communication in improving nursing handoff quality in inpatient settings. Journal of Nursing Practice, 5(1), 55–61. https://doi.org/10.32584/jnp.v5i1.308
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Shaoru, H., Lin, Z., & Kim, Y. (2023). Alarm fatigue and nursing responses in high-acuity environments: Strategies for prevention. International Journal of Nursing Sciences, 10(3), 210–218. https://doi.org/10.1016/j.ijnss.2023.06.002