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NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

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Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

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Root-Cause Analysis and Safety Improvement Plan

Inadequate patient education is a common quality and safety concern in the healthcare sector. This Root-Cause Analysis (RCA) is performed to analyze a clinical scenario where a lack of patient education led to harmful consequences for a patient at Miami Valley Hospital. This assessment analyzes the root causes of the situation, applies evidence-based best practices to address the concern, develops a safety improvement plan for the particular organization, and identifies the existing organizational resources to address the concern using the proposed safety improvement plan successfully.

Analysis of the Root Cause

The case scenario for this assessment is from the Miami Valley Hospital. On November 15, 2023, Olivia, a registered nurse, discharged her patient, Mary, who was recently diagnosed with diabetes. To control her hyperglycemia, Mary was prescribed insulin as take-home medication. Her discharge prescription stated to administer She was ten units of insulin Lantus at night.

Since Olivia had a hectic shift managing five chronic patients, she could not adequately instruct Mary on using insulin pens. A few days later, the patient was received in the emergency room for fluctuating blood glucose levels. Upon investigation, the emergency team identified that the patient had inadvertently taken incorrect doses of insulin while failing to recognize hypoglycemia symptoms. The problem significantly impacted patient safety by risking her for complications related to hyperglycemia and hypoglycemia. 

While analyzing the situation, we can infer that adequate patient education is necessary to avoid several medical errors, ultimately preventing patient health complications related to medication action and utilization. A study states inadequate medication education is a significant patient safety and quality concern (T et al., 2022). Some root causes of the situation are inadequate patient education, staff workload, and ineffective nurse-patient communication. Lack of patient education is a systemic issue persisting in all healthcare settings.

Adequate patient education is essential to improve patient outcomes, enhance patient experiences, and reduce healthcare costs by encouraging patient engagement (Johnson et al., 2023). Conversely, a lack of patient education may lead to poor health behaviors, eventually making room for health complications. Secondly, nurses’ workload is contemplated as an essential root cause for both inadequate patient education and medication errors. Banda et al. (2022) presented a study showing that nurses’ workload directly impacts patient safety. These effects include poor care quality, lack of patient engagement, and medical errors. It also leads to insufficient nurse-patient communication, another root cause for inadequate patient education, stemming from the nurse’s busy schedule managing multiple chronic patients.

Effective communication between nurses and patients increases patient engagement in healthcare, ultimately improving patients’ adherence to medication and treatment plans (Kwame & Petrucka, 2021). Communication is essential to ensure healthcare providers and patients work on shared goals to lessen uncertain circumstances and enhance patient safety. 

Evidenced-Based and Best Practice Strategies

Several evidence-based best practices are suggested by literature to address the quality and safety concerns of inadequate patient education and the root causes identified in RCA. These include establishing a patient-centered communication model, task delegation, and integrating patient education portals in the Electronic Health Records (EHR) system. 

Task Delegation 

Delegating nurses’ tasks allows them to distribute the workload effectively, which assists them in focusing on essential tasks that require nursing competencies (Crevacore et al., 2023). According to the literature, nurses’ workload significantly impacts patient education as it doesn’t allow nurses to efficiently engage patients in their healthcare (Akhtar et al., 2019). Therefore, delegating tasks allows nurses to allocate more time to patient care and education. Moreover, task division enables nurses to focus on their expertise, leading to more effective and tailored patient education. This way, it will address the patient safety issue of inadequate education. 

EHR Patient Education Portals 

Another evidence-based best practice to improve patient education is integrating patient portals into the EHR system. These portals provide holistic access to patients’ records, medication regimens, appointments, telehealth visits, and educational materials, allowing patients to receive comprehensive knowledge and make informed decisions about their healthcare (Johnson et al., 2023). A study mentioning the effectiveness of educational materials emphasized the need for EHR-integrated patient portals as they provide continuous education to the patients and support their decision-making for healthcare needs (Bhattad & Pacifico, 2022). Thus, these portals are essential to improve patient education in healthcare settings. 

Patient-Centered Communication Model

The patient-centered communication model focuses on improving nurse-patient communication. This model leads healthcare providers to interact with patients and identify their educational needs, preferences, and barriers to effective comprehension. The educational materials can be individualized to avoid medical jargon and remove irrelevant information to improve patient engagement and participation in their healthcare (Ricci et al., 2022). These open and accessible communication lines, centered on individual patients, will enhance nurse-patient communication, eventually augmenting patient health literacy levels, informing health behaviors, minimizing errors, and maintaining patient safety. 

Safety Improvement Plan

The evidence-based safety improvement plan proposed for Miami Valley Hospital is a two-pronged approach allowing interdisciplinary teams to address the safety issue of inadequate patient education. The plan includes establishing a patient-centered communication model and integrating the patient portal into the EHR system. 

Patient-Centered Communication Model

To address communication issues as a root cause for inadequate patient education, the essential required action is training healthcare professionals, especially nurses, about patient-centered communication principles. These include empathetic (respect and active listening) and culturally sensitive interactions (Kwame & Petrucka, 2021). Another process is integrating structured communication protocols into nursing workflows to ensure dedicated time for patient education. The organization should have a policy and protocols to improve discharge education by providing individualized educational materials to ensure patients acquire knowledge in home settings, preventing adverse outcomes (Banzon, 2023).

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

The goal is to reduce medication and treatment errors and associated complications by improving patient education and promoting a trusting and collaborative provider-patient relationship. The timeline required for establishing a patient-centered communication model is six months; initially, in the first three months, the organization will develop and implement training programs for nursing staff on patient-centered communication, and in the next three months, stakeholders must establish a discharge education policy and start pilot implementation. 

Integrated EHR Patient Portals

The organization should train healthcare providers on using EHR-integrated patient portals for educational purposes. This training should include primary EHR navigation, integrating educational materials, modifying the content according to patient’s needs, and addressing barriers patients may encounter while using these tools (Hodgson et al., 2022). Organizational changes include developing standardized educational materials within the EHR system to reinforce consistent knowledge and encourage treatment compliance and implementing a policy to document patient education reports in EHR, guaranteeing the coverage of comprehensive topics.

The goal is to optimize the use of EHR-integrated patient portals and enhance the availability of healthcare information, enabling them to review it continuouslyEHR patient portal will require 4-6 months for successful implementation. Initially, stakeholders will collaborate with IT teams to integrate educational materials into the existing EHR system and ensure patients have adequate access to the EHR portal. This action also requires monitoring privacy and security issues related to patient health information. 

Organizational Resources 

Existing organizational personnel, such as clinical educators, are essential for the safety improvement plan. The best way to leverage them is by utilizing their competencies to design high-quality content for healthcare providers, ensuring they receive training according to the standards set for patient-centered care (Kaarlela et al., 2022). They will also assist in developing educational materials for EHR portals. Another team from the IT department will help streamline the integration process of EHR and patient portals and address technical and security issues that may arise during execution. Leveraging the existing quality assurance team will aid in identifying loopholes to make continuous improvements. 

On the other hand, the resources that would be leveraged are computers at nursing stations and the organization’s existing EHR system. According to the priority, resources that need to be obtained include a user-friendly EHR interface. This is prioritized as the organization needs a seamless system to support patient portals and ensure strict security channels. The second priority is some educational materials to ensure standardized protocols and professional information to add to the content. Lastly, the organizations must collaborate with external experts for specialized training, which will enhance the plan’s impact, ultimately harnessing organizational resources to maximize the success of the safety improvement plan.  


In conclusion, inadequate patient education is an alarming concern for healthcare organizations requiring immediate interventions. The issue encountered by Miami Valley Hospital is an explicit example of harmful complications of lack of patient education. Thus, we described some evidence-based best practices and developed a safety improvement plan entailing a patient-centered communication model and EHR-integrated patient portals to enhance patient engagement, make information accessible to the patients, and improve patient education to reduce the risk of errors and improve patients’ well-being. 


Akhtar, N., Hussain, M., Afzal, M., & Gilani, S. (2019). Factors influencing practice of patient education among nurses. Saudi Journal of Nursing and Health Care2(4), 116-128. https://doi.org/10.21276/sjnhc.2019.2.4.1 

Banda, Z., Simbota, M., & Mula, C. (2022). Nurses’ perceptions on the effects of high nursing workload on patient care in an intensive care unit of a referral hospital in Malawi: A qualitative study. BMC Nursing21, 136. https://doi.org/10.1186/s12912-022-00918-x

Banzon, C. (2023). Discharge education protocol to improve patient satisfactionSouth Dakota State University. https://openprairie.sdstate.edu/cgi/viewcontent.cgi?article=1185&context=con_dnp 

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus14(7), e27336. https://doi.org/10.7759/cureus.27336 

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Crevacore, C., Jacob, E., Coventry, L. L., & Duffield, C. (2023). Integrative review: Factors impacting effective delegation practices by registered nurses to assistants in nursing. Journal of Advanced Nursing79(3), 885–895. https://doi.org/10.1111/jan.15430 

Hodgson, J., Welch, M., Tucker, E., Forbes, T., & Pye, J. (2022). Utilization of ehr to improve support person engagement in health care for patients with chronic conditions. Journal of Patient Experience9, 237437352210775. https://doi.org/10.1177/23743735221077528 

Johnson, A. M., Brimhall, A. S., Johnson, E. T., Hodgson, J., Didericksen, K., Pye, J., Harmon, G. J. C., & Sewell, K. B. (2023). A systematic review of the effectiveness of patient education through patient portals. JAMIA Open6(1), ooac085. https://doi.org/10.1093/jamiaopen/ooac085 

Kaarlela, V., Mikkonen, K., Pohjamies, N., Ruuskanen, S., Kääriäinen, M., Kuivila, H.-M., & Haapa, T. (2022). Competence of clinical nurse educators in university hospitals: A cross-sectional study. Nordic Journal of Nursing Research42(4), 195–202. https://doi.org/10.1177/20571585211066018 

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing20(1), 158. https://doi.org/10.1186/s12912-021-00684-2

Ricci, L., Villegente, J., Loyal, D., Ayav, C., Kivits, J., & Rat, A. (2022). Tailored patient therapeutic educational interventions: A patient‐centred communication model. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy25(1), 276–289. https://doi.org/10.1111/hex.13377

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

T, R., I U, H., M Y, M., & P, G. (2022). Patients’ knowledge about medicines improves when provided with written compared to verbal information in their native language. PloS One17(10), e0274901. https://doi.org/10.1371/journal.pone.0274901 


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