Capella FPX 4035 Assessment 2

Understanding What Happened

1. What happened?: Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context. 
   • Who did the problem/event affect, and how?

A breakdown in nurse handoff communication at a hospital during a shift change produced a critical incident that caused harm to a 56-year-old female patient with acute heart failure (AHF). The outgoing nurse failed to share crucial information due to a communication gap regarding recent modification in the patient’s diuretic schedule, recorded that the patient had increasing signs of retention with higher blood pressure, and a 5 lb gain in two days. The new nurse did not know of these changes and did not pay attention to the prevailing monitoring of the patient’s fluid status or vital signs. As a result, the patient’s condition resulted in acute pulmonary edema of severe character, such as aggravated shortness of breath and an ensemble of crackles audible over both lung fields, which required urgent administration of intravenous diuretics and non-invasive ventilation. The inadequate handover due to insufficient staff and time restrictions leads to ignoring risks. Further, the outgoing nursing team failed to document the patient’s most recent clinical findings, ignoring the patient handoff protocol. When the duty staff realized the crisis, the patient needed emergent transfer to the ICU, delaying her recovery.

Due to poor patient handoff, the patient’s health deteriorated, causing distress, while her family faced emotional stress. Further, Medical staff experienced emotional anguish, inquiries into protocol adherence, and possible disciplinary penalties. This event also affects the hospital’s reputation and creates a financial burden due to additional care. Evidence showed that 40.1% of communication gap-related negative events are due to poor patient handoff, leading to injury, a lower standard of care, prolonged hospitalizations, higher expenses, and even deaths (Nawawi & Ibrahim, 2024).

1. Why did it happen?:
   • Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.
   • System Factors: Examine workflow processes, equipment failures, and environmental factors.
   • Organizational Culture: Assess if there are cultural issues, lack of safety culture, or inadequate leadership support
   • Society/Culture: What role might cultural assumptions or backgrounds play?

Human Factors: Major human problems that led to this severe event included poor handoff communication, as the outgoing nursing staff could not document all the vital patient details. Further, due to staff shortage, nurses experienced fatigue on long shifts and were overworked, which resulted in distracted attention. Lastly, poor knowledge and compliance with the structured handoff protocol prevented the complete sharing of critical clinical data during handoff. According to Nawawi and Ibrahim (2024), time restrictions, secrecy, and the possibility for less collaboration are all connected factors among nurses. Also, a shortage of time could be related to staffing ratios or the requirement for nursing staff to conduct non-nursing responsibilities.

System Factors: Lack of standardized hand-off protocols, time-pressured staff, and chaotic environment impeded communication, lack of EHR tool for documentation, checklists, or alerts allowed critical data gaps. Nawawi and Ibrahim (2024), asserted that without a handoff protocol, there may be inaccurate and partial transfers of patient care duties, resulting in mistakes and lapses in care.

Organizational Culture: The organizational culture has contributed to the event with poorly prioritized safety, inadequate leadership emphasis on structured communication (SBAR), and acceptance of rude, inconsistent handoffs. Nawawi and Ibrahim (2024), asserted that hospitals can enhance handoff efficiency and prevent adverse occurrences by employing standardized handoff equipment and practices. Further, the absence of psychological safety and fear of blame could have prevented staff from sharing concerns; the failure of leadership to model accountability, to offer training, or to audit processes has eroded a culture of reliability during care transitions.

Society/ Culture: Cultural preconceptions, language obstacles, and disparities in communication styles among varied personnel could have resulted in misunderstandings, reducing the precision of the handoff.

1. Was there a deviation from protocols or standards?:
   • Procedures and Policies: Determine if established protocols were followed or if there were deviations.
   • Were there any steps that were not taken or did not happen as intended?
   • Documentation: Review medical records, nursing notes, and other relevant documentation.

Deviations from protocols have occurred. Existing handoff procedures were not followed, and critical clinical updates were missed during inter-shift transitions. The required documentation of the patient’s worsening health was not completed, which violated documentation guidelines. For example, the outgoing nurse failed to document important AHF-specific updates like an increase in weight by 5 pounds, worsening edema, and elevated blood pressure. The exiting nurse submitted an incomplete verbal report, failing to ensure that all vital patient information had been conveyed. Furthermore, no robust verification method was used to provide the transfer and comprehension of patient vital details. Important measures were overlooked, like double-checking medicine prescriptions and confirming exceptional medical needs. The expected oral handoff among nurses during care transition was omitted. The receiving staff failed to pose questions to clarify, presuming that all pertinent details had been documented. Minagorre et al. (2023), advocated that in oral handoffs, patient details must be communicated face-to-face between personnel engaged in care provision. A proper bedside information transfer was not performed. Analyzing clinical records showed a gap in practice. Detailed documentation of the patient’s current status and upcoming interventions was missing. Nursing notes were uncompleted, lacking important information about recent evaluations and practices such as monitoring blood pressure and body weight, diuretic adjustments, and drug delivery. This lack of documentation caused delays in receiving crucial care, leading to patients’ adverse conditions. Precise documentation in medical records is essential for ensuring easy access to vital data for all teammates, leading to precise handoffs and patient care (Nawawi & Ibrahim, 2024).

1. Who was involved?:
2. Staff: Identify the roles of individuals directly involved in the event.
3. Supervisors and Managers: Investigate

Among staff, the departing nurse and the receiving nurse are both accountable for the adverse event. The outgaining nurse failed to communicate even verbally about the CHF patient condition updates, such as a 5-pound weight gain, worsening edema. She also did not document details completely, ignoring the handoff protocol. Further, the doctor changed the prescription and added IV diuretics for the patient. However, due to a communication gap, this detail was not transferred to the receiving nurse. While the receiving nurse failed to pose questions to clarify, presuming that all pertinent details had been documented. She did not have critical information, leading to delayed IV diuretics. The handoff breakdown delayed the ability to identify a fluid overload, leading to acute pulmonary edema. Patient handovers are an important driver of drug mistakes, most commonly due to failure in interactions among caregivers (Minagorre et al., 2023). Upon investigation, it was found that the unit manager and the nurse supervisor were also accountable for the negative event. They did not supervise whether handoff protocols were followed during shift changes or not. The nurse supervisor had not conducted training for formal communication methods such as SBAR. Managers neglected to perform periodic inspections of deficiencies in precise handoffs. Their ignorance leads to inadequate handoff due to non-compliance with standard protocols and communication breakdown.

1. Was there a breakdown in communication?:
   • Interdisciplinary Communication: Assess how well different teams communicated.
   • Patient-Provider Communication: Explore whether patients were informed and understood their care.

The nursing staff (including outgoing and receiving nurses) and the other medical team could not communicate effectively. The exiting nurse failed to appropriately communicate crucial information to the incoming nurse, including altering prescriptions and monitoring vital signs. Furthermore, the physician’s changed prescription was not adequately communicated to the receiving nurse, causing delays and risks for patient health. Research advocated that drug administration must follow standard clinical standards during handoffs, explicitly declaring any modifications, ensuring proper drug reconciliation, and preventing discrepancies (Minagorre et al., 2023). Furthermore, there was minimal communication between patients and providers. The patient did not receive appropriate information regarding the course of therapy and medication plan. Because of the communication breakdown during the handoff, the patient did not receive a thorough explanation of their updated care plan, which could have impacted their knowledge of the condition and their treatment expectations. The patient was unaware of her condition and unable to tell about her changing medical condition, which led to severe complications.

1. 1. What were the contributing factors?:
      • Physical Environment: Consider facility layout, equipment availability, and workspaces.
      • Staffing Levels: Evaluate if staffing was adequate.

• Training and Competency: Assess staff’s knowledge and skills.

Physical Environment: The communication breakdown was caused by the facility layout and the chaotic environment. Common computers in busy locations slowed down the EHR updates on edema progression or diuretic modifications. The handoff took place at a centralized station from the patient’s room, eliminating the possibility of promptly sharing patient vital information during the transition process. Improper charting areas also distracted nurses from recording patient critical details in nursing notes during handoff. For example, in this case, subtle AHF decompensation signs lead to adverse incidents.

Staffing Level: This event occurred due to insufficient staff. Understaffing led to long duty hours for nurses. They experienced fatigue and overwork, which resulted in distracted attention and insufficient data documentation. Further, the overwhelming staff contributed to the communication gap and failures in handoff protocol compliance. According to Minagorre et al. (2023), personnel’s overwork, juggling multiple tasks, and intricacy of care all raise the likelihood of handling data errors and poor communication during handoff.

Training and Competency: In the context of this event, however, the nurses are competent in effective patient care. However, a lack of knowledge and training regarding effective communication tools like SBAR and awareness of standard handoff guidelines led to a gap in practice, leading to missing patient details during handoff. Nawawi and Ibrahim (2024), stated that, to avoid unfavorable episodes in patient care caused by untrained or less capable staff, handoff staff must receive training and instruction. Ongoing training helps nurses increase their ability and trust while reducing communication issues and medical mistakes. Ongoing training guarantees competent handoff professionals.

1. Did organizational policies or procedures play a role?:
   • Policy Compliance: Investigate if policies were followed.
   • Policy Clarity: Assess if policies are clear and accessible.

A departure from set-down patient handoff and care protocols characterized the event. Staff did not adhere to the standardized processes to provide critical clinical updates when shift transitions occurred, resulting in information gaps (such as neglect to mention worsening symptoms or medication modification). Although there were handoff policies for a structured handoff, they were unclear and inaccessible. Staff faced problems identifying new or interpreting updated guidelines, leading to insufficient handoffs. They are also unclear about standards related to documenting data in EHR, such as symptom severities or dosage changes, which contribute to care delays. Systemic policy deficiencies and poor adherence to handoff interventions can worsen the patient’s condition.

1. Was there a failure in monitoring or surveillance?:
   • Vital Signs Monitoring: Check if there were any missed signs.
   • Alarm Fatigue: Explore if alarms were ignored.

There was inadequate post-handoff monitoring that impaired the detection of the deterioration of the AHF patient’s fluid overload. Obligatory checks, body weight, blood pressure trends, and edema severity were skipped, thus postponing the realization of a 5-pound increase and heightened jugular venous pressure. Frequent nonurgent alerts caused alarm fatigue, desensitizing the staff to life-threatening alerts like hypertension increases or lung auscultation crackles. Such omissions created an opportunity for acute pulmonary edema, which resulted in an urgent need for diuretic administration. Poor emphasis on critical indicators monitoring and ignoring alarms directly affecting the timely drug delivery, representing systemic flaws in patient-tailored monitoring of high-risk cases. Alsuyayfi and Alanazi (2022), stated that alarm weariness can compromise patient security and result in life-threatening situations. To avoid adverse occurrences and guarantee patient safety, hospitals must adopt suitable procedures to alter monitor variables based on the patient’s state.

1. What can be learned to prevent recurrence?:
   • Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.
   • Quality Improvement: Consider implementing preventive measures.

Systematic improvements, such as enhancing communication methods and ensuring employees are taught to recognize potential indications, are required. Training on the significance of ongoing vital sign monitoring, particularly in critical situations, can help prevent similar problems. Further, implementing tools like SBAR and encouraging staff to comply with these protocols will help improve handoff practices and the exchange of vital details. Creating a setting of safety and responsibility, in which employees are encouraged to speak up and report incidents, is critical. Kim et al. (2020), stated that implementing a safety culture impacts patient security and handoff. A robust collaborative culture facilitates an efficient handoff of medical information and ensures accountability of all personnel. Preventive steps such as implementing effective surveillance systems, optimizing alert management processes are required. Hand off Periodic inspections must be conducted to ensure continual enhancement of quality. Lastly, handoff checklists implementation can assist in guaranteeing effective information exchange. Minagorre et al. (2023), asserted that checklists provide the controlled and uniform management of key data, averting the loss of crucial data during data transition. 

1. 1. How can patient safety be enhanced?:
      • Risk Mitigation: Develop strategies to minimize risks.
      • Education and Training: Ensure staff are well-trained.

• Reporting and Feedback: Encourage open reporting and learning from mistakes.

To avoid the risks and improve patient security, standardize handoffs using structured tools (e.g., SBAR checklists), incorporated in EHRs for completeness in patient details. Minimize risk by establishing quiet, interruption-free areas for verbal handoffs, insisting on dual verification of the critical update (medication changes, vital trends), and designing automatic alerts for missing data. Train staff using simulations in the domains of clarity in communication, awareness of situations, and escalation procedures. Evidence showed that simulation training has proven useful in increasing handoff effectiveness while enhancing nurses’ self-assurance and interpersonal abilities (Nawawi & Ibrahim, 2024). Enhance the accountability through audits and feedback loops. Encouraging reporting undesirable occurrences and incidents resulting from communication mistakes is vital for quality enhancement in handoff processes (Minagorre et al., 2023). Lastly, empower patients and their families to inquire during transitions, promoting accountable accuracy.

Root Cause – the most basic reason that the situation occurred

Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal

HFC

HF T

HF

F/S

E

R

B

Communication Gap

Workload and Time Constraint

Lack of protocol compliance 

1

Communication gap among staff leads to an insufficient transmission of patient vital details. Which causes misunderstanding and delay in care, impacting patient safety.

HFC

2

Due to insufficient staffing, nurses have to work long duty hours and multitask, which causes fatigue and exhaustion. It also impairs reasoning and concentration, increasing the probability of errors and leading to insufficient patient data exchange, which can cause adverse events.

HFF

3

Organizational concerns, like improper adoption of standard communication protocols and unclear or noncompliance with handoff guidelines, lead to omitted data and cause ambiguity during transition.

R

Improper patient handoff at the bedside is notably due to insufficient communication among caregivers, leading to adverse incidents. Kim et al. (2020), found that poor handoffs cause over 40.2% of negative occurrences, such as medical mistakes and patient fatalities. About 22.3% of negative effects connected with nursing care coincide with inadequate communication during information exchanges. Besides the communication gap, other factors are also involved, including staff and organizational-related issues. These factors include adopting ineffective communication tools, insufficient time for handoffs, breaks or disturbance of handoffs, lack of standard handoff protocols, and understaffing (Kim et al., 2020). Further lack of nurses’ training on communication tools like SBAR and handoff guidelines like to inproficiency and non-compliance, compromising patient safety. Adopting evidence-based practices is crucial to ensure proper handoffs at bedsides and boost patient safety. Initially, enhancing the handoff process through standardized protocols, rules, and integrating EHRs is recommended to maintain continuity of treatment while also improving reliability and accuracy by enabling quick availability of patient data (Nawawi & Ibrahim, 2024). Secondly, interdisciplinary handoff huddles, brief, planned sessions involving doctors, nurses, and pharmacists, help to lessen the chance of knowledge loss. These meetings allow for real-time development of treatment plans, drug modifications, and other possible issues. Marquez et al. (2024) underline that such cooperation strategies help to reduce omissions and mistakes that occur during verbal communication of data or in the absence of validation. Thirdly, offering staff training on equipment use and protocols is critical for ensuring safety. Nawawi and Ibrahim (2024) advocated that Formal handoff coaching is essential for interaction and collaborative capabilities. Simulation-based instruction has been shown to improve handoff competence while also increasing nurse trust and interpersonal skills. Fourthly, adopting effective tools like SBAR and checklists for handoffs can help ensure precise data exchange, reducing the risk of omission. Mulfiyanti and Satriana (2022), stated that efficient SBAR communication improves care service quality and patient happiness, and is crucial for the successful deployment of patient handover. Lastly, conducting inspections and taking staff feedback is crucial to ensure a safe culture and improve practices.

To tackle the stated safety concerns, employing EHR with incorporated handoff checklists standardizes documentation and gives actual-time access to current medical information. These technologies can enhance the handoff procedure, guaranteeing no vital information is overlooked and that care transfers are secured. Further, using standardized communication methods such as SBAR can enhance the handover process, providing clear and accurate information flow across teams, improving service quality (Mulfiyanti & Satriana, 2022). It will prevent mistakes caused by communication gaps. Ongoing education and simulation exercises concentrating on correct equipment use and handoff processes can help to close employee skill gaps while avoiding issues in handoffs like inadequate tool use. Training on the handoff process can explicitly address information-related difficulties, resulting in complete documentation. Conducting interdisciplinary huddles will assist in addressing concerns related to patient condition and ensure collaboration and thorough information exchange (Marquez et al., 2024). Regular security reviews can aid in detecting trends in sentinel incidents and possible shortcomings, offering an opportunity for quality enhancement. These solutions assist in fostering a culture of safety, avoiding negative events.

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

For the communication gap, enforce structured handoff tools such as EHR-embedded SBAR checklists) with mandated fields for the vital signs, medication changes, and patient-specific risks.

E

2

For time constraints, hold protected handoff times (10-15 minutes/shift) for nurses to eliminate multitasking. Adopt automated EHR data summaries to make reporting easier.

C/E

3

For protocol compliance, offer training and integrate real-time compliance alerts into the EHR, such as alerts for missing handoff documentation.

E

Various new procedures and regulations will be implemented to address the root issues. First, an established communication procedure, such as SBAR, will be deployed throughout all patient handoff circumstances to improve information sharing. This will be reinforced by ongoing staff education and training initiatives that emphasize effective communication. These trainings will help to enhance nurses’ communication abilities and confidence (Nawawi & Ibrahim, 2024). Secondly, an organizational work-related and handoff policy will be implemented to address the nursing issue of time limitation, in which nurses will be offered protected handoff time. It will help them to thoroughly discuss and exchange patient vital data during shift change, enhancing handoff practice. Thirdly, the hospital will implement EHR-integrated handoff tools and checklists to ensure precise patient data documentation in care transfer. Minagorre et al. (2023), asserted that checklists provide the controlled and uniform management of key data, minimizing the loss of crucial data during data transition. Lastly, continuous professional development will provide workers with the necessary abilities to adapt to these new processes, resulting in a higher standard of care. These techniques strive to foster an atmosphere of safety and preparation that is consistent with standard procedures and proven methods in patient care

The goals include:

1. 1. Implementation of standard communication methods like SBAR reduces misunderstandings and facilitates effective data exchange during handover, improving patient care.
   2. Implementing an updated EHR with incorporated handoff tools and checklists to avoid negative events and ensure a safe culture.
   3. Implement standard handoff protocols and offer protected handoff time to nurses to thoroughly exchange data during handover and precise documentation, avoiding care delay and medical errors.

• Conducting staff training on handoff guidelines, effective use of tools, and adopting communication procedures to improve staff competency and care practices.

The desired results related to these goals are to enhance the standard of care practices, ensure a safety culture, minimize medical errors and negative incidents, and improve staff proficiency in offering reliable care.

Timeline: These initiatives will be implemented in six months

In the initial first two months, the standard communication protocol will be implemented with the cooperation of a multidisciplinary team, including safety staff, quality enhancement team, nurses, doctors, and administrators. Medical staff will be provided with an initial training session on communication protocols. 

In the next phase, in three to four months, the EHR system will be updated, ensuring the incorporation of handoff softwares and checklists to ensure precise patient data entry and transfer during handoff. For this purpose, technical staff will be involved to ensure the effective adoption and functioning. Further, modifications in organizational policies will occur, and protected handoff duration and standard protocols will be integrated.

In the last phase, comprehensive staff training will be conducted, educating staff about updated organizational policy and improving their understanding and skills related to EHR and checklists to ensure seamless operations and avoid negative events. Further, regular audits and monitoring will be conducted to address any issues that occur and find opportunities for improvement.

Adequate assets are vital to ensure the success of the advancement plan. These assets entail human resources, like a well-qualified trainer, that are needed for staff training to guide staff on policy changes, effective communication procedures, and hand-off practices. A technical expert is also required to guide staff on using EHR and related tools effectively. Financial resources and education-related materials, including simulation activities, will also be needed to conduct workshops. The estimated expenses will be $1000. Simulation training has proven useful in increasing handoff effectiveness while enhancing nurses’ self-assurance and interpersonal abilities (Nawawi & Ibrahim, 2024).

Resources needed to upgrade the already existing EHR system and integrate handoff tools and checklists. Expertise of the IT staff will be required to improve the system performance. The fiscal budget needs around $15,000. Data evaluation tools will also be needed to analyze matrices and assess the efficacy and impact of the improvement plan on patient outcomes. The cost of a data analytical tool will be around $25000. Further, assets are crucial for effectively adopting SBAR tools for better handoff. For example, organizations like the Cleveland Clinic have implemented SBAR tools for efficient handoff communication. It ensures uniform and precise patient data sharing throughout significant occurrences, including shift transfers (Cleveland Clinic, n.d.).

Existing Resources

Strategic utilization of already existing assets also promises the effectiveness of the advancement plan. For example, the existing EHR systems can be modified to incorporate checklists, compliance alerts, and automatic handoff summaries without significant changes in the software. IT teams can repurpose the existing systems.  These checklists, integrated in EHR, provide the controlled and uniform management of key information, preventing critical data loss during data transition (Minagorre et al., 2023). Existing staff expertise can be utilized for training purposes; already hired nurse educators and clinical informaticists can facilitate SBAR training and customization of EHR tools, cutting down on external consultant expenditures. Nurse informatic experts play a significant role in developing EHR processes that enable communication among nurses during handover. Her position is critical in ensuring that a robust communication tool is promptly available and user-friendly (Anderson, 2024). Further, administrators are crucial to managing fiscal resources and conducting improvement initiatives effectively. Sufficient funding and human resources are vital to effectively executing the safety advancement plan and improving care quality.