NURS FPX 4035 Assessment 2

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

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 represent critical, unexpected incidents that involve death or serious physical or psychological harm, not attributable to the natural progression of a patient’s illness. These events serve as serious indicators of underlying vulnerabilities in healthcare safety systems. Conducting a comprehensive Root-Cause Analysis (RCA) is vital in identifying both immediate triggers and broader systemic flaws that may have contributed to such adverse outcomes. A properly conducted RCA enables healthcare organizations to adopt meaningful, sustainable interventions that reduce the risk of recurrence and strengthen patient safety practices.

In this particular case, the sentinel event occurred in the Emergency Department (ED) due to a communication failure during a patient handoff. A septic patient’s worsening condition was not effectively conveyed by the outgoing nurse because of omitted critical information and incomplete documentation. The result was a significant delay in treatment, leading to prolonged hospitalization and intensified medical interventions. This event impacted various stakeholders, including the patient, who suffered physical deterioration and emotional stress; the family, who experienced anxiety and distress; and the healthcare team, who faced increased workloads, moral injury, and potential professional consequences. Additionally, the healthcare institution underwent scrutiny from regulators, suffered financial strain, and experienced reputational damage.

The contributing factors to this incident were both human and systemic. Key human elements included fatigue, overwhelming workload, and insufficient training, all of which contributed to incomplete handoffs. Systemically, disorganized workflows and a lack of structured digital communication tools exacerbated these issues. Furthermore, the organizational culture did not adequately prioritize safety, leadership oversight, or accountability. Differences in staff language and culture also led to miscommunication. Collectively, these components underscore the importance of addressing both individual behavior and systemic infrastructure in patient safety initiatives.

Communication Breakdown and Systemic Weaknesses

A significant procedural lapse was the failure to follow the SBAR (Situation, Background, Assessment, Recommendation) protocol during the handoff process. Critical patient data was omitted, and there was no verification to ensure mutual understanding between healthcare providers. Nursing documentation lacked key updates, such as pending interventions or scheduled medications, which delayed time-sensitive care. This lapse highlighted the absence of a reliable structure for information exchange during transitions.

This incident also revealed weaknesses in communication between healthcare disciplines and between providers and patients. Nurses failed to communicate important medication updates, and the patient was left uninformed about changes in their care plan. This lack of transparency may have undermined the patient’s trust in the healthcare system. These breakdowns demonstrate the importance of reinforcing standardized communication tools and regularly training staff on their use.

Environmental limitations further worsened the situation. Inefficient nursing station layouts and equipment failures impeded effective care coordination. Staffing shortages resulted in nurse fatigue, decreasing their attention to protocol compliance. Although staff competency was generally acceptable, notable gaps in training—particularly concerning newly implemented handoff protocols—were evident. Moreover, many healthcare professionals reported difficulty in accessing current procedural guidelines, creating inconsistencies in care delivery. Alarm fatigue was another compounding factor; critical alerts were missed due to frequent, non-prioritized notifications, reducing the staff’s responsiveness to emergent issues.

Safety Enhancements and Preventive Strategies

This sentinel event underscores the need for multifaceted safety improvements. Strengthening communication protocols through reinforced SBAR training and structured bedside handoffs is paramount. Staff education should be recurrent and involve simulation-based training, enabling healthcare workers to practice real-time responses to high-risk situations. A cultural shift toward safety, openness, and accountability must also be promoted throughout the organization.

Preventive strategies include optimizing monitoring systems, enhancing alarm protocols, and introducing checklists for critical transitions of care. Continuous audits and real-time feedback loops can help detect and address safety gaps proactively. Developing a non-punitive reporting environment encourages staff to report near misses and adverse events, facilitating organizational learning. Leadership support is essential in fostering this culture and ensuring the translation of incident analysis into systemic improvement.

Root Cause and Contributing Factors Table

Root Cause / Contributing Factor	Category	Code
Breakdown in communication between the care team, leading to misinterpretation of patient condition	Human Factor – Communication	HF-C
Insufficient training on updated protocols, causing staff to miss critical care changes	Human Factor – Training	HF-T
Malfunctioning equipment led to missed warning signs and delayed intervention	Environment / Equipment	E
Staff fatigue due to poor scheduling affected attention and decision-making	Human Factor – Fatigue/Scheduling	HF-F/S
Failure to follow safety protocols resulted in missed interventions	Rules / Policies / Procedures	R
Organizational barriers, including poor communication channels, hindered effective teamwork	Barriers	B

Code Key: HF-C = Human Factor – Communication HF-T = Human Factor – Training HF-F/S = Human Factor – Fatigue/Scheduling E = Environment / Equipment R = Rules / Policies / Procedures B = Barriers

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

Application of Evidence-Based Strategies

Effectively addressing sentinel events involves implementing evidence-based strategies that account for both human behavior and systemic deficiencies. One proven method is the use of structured communication tools such as SBAR. A study conducted at the Griyatama Inpatient Room at Tabanan Hospital demonstrated that consistent SBAR use significantly improved communication during patient handoffs and emergency situations (Putra, Wardani, & Sari, 2022).

Alarm management is another critical area for improvement. Alarm fatigue has been widely recognized as a leading contributor to delayed responses. Research by Cvach (2012) suggests that reducing unnecessary alerts and prioritizing critical alarms can significantly improve staff response times. Incorporating automated alert systems that monitor abnormal vital signs can enhance patient surveillance and reduce the likelihood of missed clinical deteriorations.

Routine simulation training and refresher programs are also essential. These allow healthcare staff to rehearse responses to emergent events, solidify knowledge of evolving protocols, and improve overall clinical preparedness. Cultivating a culture that supports open incident reporting and feedback—without fear of retribution—is equally vital. Such transparency enables organizations to transform adverse events into meaningful improvements in patient care delivery.

References

Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation & Technology, 46(4), 268–277. https://doi.org/10.2345/0899-8205-46.4.268

Putra, A. A., Wardani, E. Y., & Sari, K. (2022). Implementation of SBAR communication method to improve handover effectiveness in inpatient care. Journal of Nursing Practice, 6(1), 23–29. https://doi.org/10.30994/jnp.v6i1.199