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

A sentinel event refers to an unexpected occurrence involving a patient that results in death, serious physical or psychological injury, or the risk thereof. These incidents not only affect the patients and their families but also take a toll on the healthcare team involved. Sentinel events are critical learning opportunities, prompting thorough root-cause analyses to identify both direct and systemic failures within the healthcare system. By addressing these causes, organizations can mitigate risks, improve protocols, and cultivate a stronger safety culture.

Understanding the Sentinel Event

The incident in question occurred in the Emergency Department (ED), where a septic patient experienced delayed care due to poor communication during a nurse shift handoff. Vital information regarding the patient’s condition was omitted in the verbal exchange, and documentation was incomplete. Consequently, the patient’s health deteriorated, leading to a prolonged hospital stay and additional treatments. The situation also imposed emotional distress on the patient’s family and operational strain on staff and hospital resources. This failure exposed significant gaps in communication, staffing, training, and organizational policy adherence.

Upon investigation, it was clear that multiple interrelated factors contributed to the event. Human factors like staff fatigue, communication barriers, and lack of structured handoff procedures were evident. System-level issues included an inefficient workflow and environmental distractions in the ED. Organizational culture also played a role, with limited emphasis on safety practices and poor leadership oversight. Moreover, societal and cultural challenges, such as language differences among a diverse staff, may have added to the miscommunication during transitions of care.

Communication and Protocol Deviation

The incident involved a deviation from the hospital’s established handoff procedures, specifically the SBAR (Situation, Background, Assessment, Recommendation) communication tool. The outgoing nurse failed to deliver a comprehensive report, and the incoming nurse did not verify the critical details, leading to misinterpretation of care priorities. A bedside handoff was not performed, and medical records lacked essential updates, contributing to delays in administering timely interventions. Both the charge nurse and supervisory staff failed to enforce handoff protocols or ensure that routine audits were conducted.

In addition to nurse-to-nurse communication gaps, there was a lapse in interdisciplinary coordination. Physicians’ medication orders were not clearly conveyed to the nursing team, resulting in treatment delays. Furthermore, the patient and their family were not adequately informed about the treatment plan or medication changes, impacting their ability to engage in care decisions. These failures highlight the need for a multifaceted approach to improving communication across all levels of care delivery.

Contributing Factors to the Sentinel Event

Several environmental and organizational factors further contributed to the event. The ED’s physical layout hindered communication efficiency, as staff workstations were located far from patient rooms. Equipment malfunctions delayed responses, and frequent false alarms led to alarm fatigue among staff, causing critical alerts to be missed. Inadequate staffing also compounded the problem, with nurses juggling multiple responsibilities under high pressure, leading to care omissions. Training gaps were also evident, as some staff lacked recent education on handoff protocols and use of monitoring equipment.

Hospital policies related to patient handoffs existed but were either unclear or not easily accessible, leading to inconsistent application. Routine monitoring of patient vital signs was insufficient, and desensitization to alarm systems resulted in slow reactions to patient deterioration. A combination of ineffective surveillance, inadequate training, and procedural noncompliance allowed this event to unfold with limited preventive intervention.

Root Cause Identification

Following a comprehensive analysis, the table below summarizes the primary root causes and contributing factors linked to the sentinel event, categorized using standardized codes.

Table 1: Root Causes and Contributing Factors

Evidence-Based Strategies and Safety Improvement Plan

Implementing evidence-based strategies is essential to preventing recurrence of similar events. Structured communication tools, targeted training, and routine audits are crucial components of an effective safety improvement plan. Studies demonstrate the effectiveness of SBAR in improving interprofessional handoffs and ensuring accuracy in critical information transfer (Mulfiyanti & Satriana, 2022). Simulation training and alarm management protocols further enhance staff preparedness and response times (Shaoru et al., 2023). Consistent root-cause analyses and feedback systems promote a culture of continuous improvement (Argyropoulos et al., 2024).

Application of Evidence-Based Strategies

To resolve the identified safety issues, hospitals should implement mandatory SBAR communication protocols for all patient transitions. Regular hands-on training should be conducted to reinforce competency in emergency equipment use and communication. Addressing alarm fatigue by optimizing system settings will help reduce desensitization. Safety audits and structured feedback processes can track protocol adherence and create accountability. Ultimately, a multidisciplinary effort is needed to embed these practices into daily operations and drive long-term cultural change.

Table 2: Safety Strategies and Their Applications

Action Plan for Future Prevention

To prevent recurrence of such sentinel events, actionable steps are outlined in the table below, aligned with each root cause or contributing factor.

Table 3: Safety Improvement Action Plan

Process and Policy Enhancements

To address the core failures, several structural changes will be introduced. SBAR will be embedded into electronic health records for easy use and monitoring. Staff will undergo routine scenario-based drills to practice responding to emergencies under real-time pressure. Alarm management workshops will train staff to prioritize responses effectively. Policies will be streamlined and made readily available via a centralized digital repository. Leadership will perform monthly audits and follow up with performance improvement plans. These combined initiatives aim to reinforce a high-reliability organization focused on safety, accountability, and continuous learning.

References

Argyropoulos, A., Singh, H., Johnson, K., & Choudhry, S. (2024). Improving patient safety through data-driven root-cause analysis: A systems approach. Journal of Healthcare Quality, 46(1), 33–42.

Mulfiyanti, A., & Satriana, I. N. (2022). The influence of SBAR communication techniques on the effectiveness of nurse handoffs. Journal of Health Communication, 14(3), 151–158.

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

Shaoru, W., Li, J., & Ren, K. (2023). Alarm fatigue in clinical settings: Interventions to reduce false alerts and improve patient outcomes. Critical Care Nursing Quarterly, 46(2), 119–126.