Capella FPX 4035 Assessment 2

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Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

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Root-Cause Analysis and Safety Improvement Plan

Understanding What Happened
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 mishap occurred in the Intensive Care Unit (ICU) during a shift change. A nurse misinterpreted the medication orders of a sedated patient on a ventilator. Unclear charting made administration of an incorrect dose of a sedative possible, and the incoming nurse failed to obtain clarification from the outgoing nurse. The wrong dose resulted in a respiratory event requiring emergency intervention and increased ventilator management time. The research involved the time of the ventilator, delaying the patient’s recovery, which increased the patient’s emotional trauma. Staff members experienced increased anxiety, scrutiny from hospital leadership, and internal audits. This incident prompted a reexamination of medication reconciliation practices, which identified gaps in staff training, documentation expectations, and communication practices that were apparent to the safety and viability of the organization.
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, a lack of safety culture, or inadequate leadership support. Society/Culture: What role might cultural assumptions or backgrounds play?	Human Factors: The error stemmed largely from a communication breakdown during shift change, where verbal clarification was skipped, and charting was vague. Staff fatigue also played a role, as the incoming nurse had just completed multiple consecutive shifts, increasing the likelihood of oversight. System Factors: No standardized medication handoff checklist was in place, and the electronic health record system lacked automated alerts for high-risk medications. The ICU’s high noise levels and time pressures also contributed to distraction and rushed processes. Organizational Culture: The unit lacked a strong culture of safety where staff felt encouraged to double-check or question unclear instructions. Leadership had not reinforced accountability or continuous training around high-alert drug management. Society/Culture: Cultural norms of deference to authority may have prevented junior staff from clarifying orders or questioning the information handed over, while language barriers between some team members may have further contributed to miscommunication.
Was there a deviation from protocols or standards?: Procedures and Policies: Determine if established protocols were followed or if there were deviations. Were any steps not taken or did not happen as intended? Documentation: Review medical records, nursing notes, and other relevant documentation.	Procedures and Policies: There was a clear deviation from established protocols. The standard ICU handoff procedure requires a face-to-face verbal report using a structured SBAR (Situation-Background-Assessment-Recommendation) format, which was not followed. Medication reconciliation protocols were also overlooked. Missed Steps: The incoming nurse did not verify the medication dosage with a second nurse, and the outgoing nurse failed to highlight changes in the sedative order. A double-check process for high-alert medications was not performed, as required. Documentation: The patient’s chart lacked clear, updated entries regarding the revised dosage and timing of administration. Nursing notes were incomplete and did not reflect the verbal instructions shared, leading to confusion and misinterpretation.
Who was involved? Staff: Identify the roles of individuals directly involved in the event. Supervisors and Managers: Investigate	Staff: The outgoing ICU nurse, who failed to document and communicate the revised sedative dosage properly, and the incoming nurse, who administered the incorrect dose without verification, were directly involved. Additionally, a pharmacist was indirectly involved, as the revised order was not flagged or clarified. Supervisors and Managers: The charge nurse on duty did not ensure a structured handoff took place and missed the opportunity to intervene. The nurse manager had not enforced regular handoff training or compliance audits, contributing to a lapse in oversight and accountability.
Was there a communication breakdown? Interdisciplinary Communication: Assess how well different teams communicated. Patient-Provider Communication: Explore whether patients were informed and understood their care.	Interdisciplinary Communication: Yes, there was a significant breakdown. The handoff between nursing staff lacked clarity and structure, and the revised medication order was not communicated effectively between the nursing and pharmacy teams. No interdisciplinary huddle occurred to confirm critical changes in the care plan. Patient-Provider Communication: Direct communication was limited since the patient was ventilated and sedated. However, the patient’s family was not promptly informed about the change in the patient’s condition or the medication error, leading to confusion, mistrust, and emotional distress.
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 ICU was overcrowded and noisy during shift change, with frequent interruptions and limited private space for handoffs. Shared workstations and a lack of designated quiet zones for report exchange increased the risk of miscommunication. Staffing Levels: The unit was understaffed, with nurses covering more patients than recommended. This led to rushed handoffs, skipped verification steps, and increased cognitive load on staff. Training and Competency: Staff training on using structured handoff tools and high-alert medication protocols was lacking. Newly hired nurses had not completed a full ICU-specific safety procedure orientation.
Did organizational policies or procedures play a role?: Policy Compliance: Investigate if policies were followed. Policy Clarity: Assess if policies are clear and accessible.	Policy Compliance: Policies were not fully followed. The structured handoff protocol and medication verification procedures were bypassed, indicating non-compliance with existing safety standards. Policy Clarity: While policies existed, they were not consistently reinforced or easily accessible at the point of care. Staff reported uncertainty about updates to handoff and medication protocols, suggesting a need for clearer communication and training on policy changes.
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.	Vital Signs Monitoring: There was a delay in recognizing changes in the patient’s respiratory status. The abnormal vital signs indicating sedation-related complications were not promptly acted upon, leading to worsening respiratory function. Alarm Fatigue: Alarm fatigue contributed to the delay. Frequent non-urgent alerts desensitized staff, causing critical alarms to be overlooked or silenced without proper assessment, delaying intervention.
What can be learned to prevent recurrence?: Lessons Learned: Identify systemic changes, training needs, and improvement opportunities. Quality Improvement: Consider implementing preventive measures.	Lessons Learned: Reinforced training on structured handoff protocols, especially involving high-risk medications, is needed. Ensuring that all staff understand and consistently apply these tools can reduce miscommunication. Regular competency assessments and simulations should be implemented. Quality Improvement: Establish mandatory double-check systems for high-alert drugs, implement quiet zones for shift reports, and enhance alarm management strategies to reduce fatigue. Introducing real-time audits and feedback loops can help ensure adherence to safety protocols and promote a culture of accountability and continuous improvement.
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.	Risk Mitigation: Implement standardized handoff tools (e.g., SBAR), create designated quiet areas for shift reports, and enforce double-check protocols for high-alert medications. Integrate real-time alerts in the EHR for medication discrepancies. Education and Training: Provide regular, mandatory training sessions on communication, medication safety, and alarm management. Use simulation-based learning for high-risk scenarios. Reporting and Feedback: Foster a non-punitive culture that encourages staff to report errors and near misses. Conduct debriefings after incidents, share lessons learned, and continuously refine protocols based on feedback.

What are the issue’s root cause (s) or sentinel event?

Root Cause – the most basic reason that the situation occurred		Contributing Factors – additional reason(s) that made a situation turn out less than ideal	HFC	HF T	HF F/S	E	R	B
The primary root cause was the breakdown in communication during the handoff. Critical information regarding medication adjustments was not properly conveyed between the outgoing and incoming nurses, leading to the error.	1	Inadequate training on structured handoff protocols and medication safety contributed to the failure. Staff were not sufficiently trained to handle high-alert medications or to use effective communication strategies during handoffs.	Human Factor – Communication	(Human Factor-training)
	2	Staff fatigue due to understaffing and long shifts led to rushed handoffs and missed verification steps, increasing the likelihood of errors.			(Human Factor-fatigue/scheduling)
	3	The noisy, crowded ICU environment created distractions and hindered effective communication during the shift change.				Environment/Equipment

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

Application of Evidence-Based Strategies

Identify evidence-based best practice strategies to address the safety issue or sentinel event.

Three key evidence-based strategies can be implemented to address the safety issue. First, adopting standardized handoff protocols such as SBAR (Situation, Background, Assessment, Recommendation) will ensure that critical patient information is communicated during shift changes, reducing the risk of omissions and misinterpretations. Research has shown that structured handoff tools significantly enhance communication and patient safety (Adam et al., 2022). Second, implementing mandatory medication reconciliation and a double-check system for high-alert medications will minimize errors. This practice involves two healthcare professionals verifying the medication order and dosage before administration, significantly reducing medication-related mistakes. Studies have demonstrated that double-checking medications leads to fewer errors and better outcomes (Lahti et al., 2022)

. Lastly, improving the workplace environment by creating quiet zones for handoff processes and minimizing distractions will foster clearer communication during critical moments. Evidence indicates that reducing environmental noise during handoffs can help ensure that important details are not overlooked, ultimately improving patient safety and care coordination (Abraham et al., 2021).

Explain how the strategies could be applied to your identified safety issues or sentinel events.

To address the safety issues identified in the scenario, implementing standardized handoff protocols like SBAR would ensure clear and structured communication between the outgoing and incoming nurses. This approach would guarantee that vital patient information, including changes in medication and critical health conditions, is properly conveyed without omissions. Using SBAR minimized the risk of miscommunication during shift changes, reducing the likelihood of medication errors and ensuring that the patient’s condition is accurately assessed and addressed. This strategy would directly prevent situations where important details, such as dosage adjustments, are overlooked or misunderstood, leading to better patient outcomes and reduced hospital stays.

In addition, instituting mandatory medication reconciliation and a double-check system for high-alert medications would significantly reduce medication errors. Having two healthcare professionals verify medication orders before administration ensures no discrepancies go unnoticed, which is especially critical in high-risk situations like sedation. Furthermore, creating quiet zones during handoff periods would minimize distractions, allowing for more focused and accurate communication. This would help prevent missed warnings or omitted information, ensuring that both nurses are fully informed about the patient’s care plan. Together, these strategies address the core issues of communication breakdown and medication administration, improving patient safety and reducing the likelihood of similar sentinel events.

Safety Improvement Plan

List any future actions needed to prevent recurrence.

Action Plan One for each Root Cause/Contributing Factor from above		E / C / Choose one
Breakdown in Communication During Handoff	Implement standardized handoff protocols like SBAR to ensure critical information is conveyed clearly during shift changes. All staff will be trained on the SBAR communication framework, and adherence to this protocol will be monitored regularly to ensure its consistent use during handoffs.	C
Staff Fatigue Due to Understaffing and Long Shifts	Address staffing levels and reduce shift lengths to prevent staff fatigue and ensure adequate rest between shifts. Introduce staffing policies that prioritize adequate nurse-patient ratios, limit consecutive shifts, and implement rotating schedules to prevent staff burnout.	E
Noisy, Crowded ICU Environment Creating Distractions	Designate quiet zones in the ICU during shift changes and ensure that handoffs occur in these areas to prevent interruptions and distractions and ensure that all communication is clear and effective.	E

E = eliminate (i.e., piece of equipment is removed, fixed, or replaced.)

C = control (i.e., additional step/warning is added or staff is educated/re-educated)

A = accept (i.e. formal or informal discussions of “do not let it happen again” or “pay better attention,” but nothing else will change, and the risk is accepted)

Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).

To address the root causes, several new processes, policies, and professional development initiatives will be implemented. A standardized handoff protocol, such as SBAR, will be mandated hospital-wide, ensuring clear and accurate communication during shift changes. Mandatory training on medication safety and structured communication will be introduced for all clinical staff, with a certification process for high-alert medications and handoff protocols. Additionally, new staffing policies will regulate nurse-patient ratios and limit consecutive shifts to prevent staff fatigue, while rotating shift patterns and mandatory rest periods will be enforced. To reduce distractions during handoffs, quiet zones will be designated in key areas, such as the ICU, with staff educated on the importance of minimizing noise during critical communication times. These changes aim to enhance communication, reduce errors, and promote a safer, more efficient healthcare environment.

Provide a description of the goals or desired outcomes of the actions listed above, along with a rough development and implementation timeline for the plan.

The primary goals of the actions outlined above are to improve communication during patient handoffs, enhance medication safety, reduce staff fatigue, and minimize environmental distractions, ultimately leading to improved patient outcomes and a safer hospital environment. Specifically, the desired outcomes include:

Improved Communication: By implementing standardized handoff protocols (like SBAR), we aim to ensure that all critical patient information is conveyed clearly and accurately, reducing the likelihood of errors and miscommunication during shift changes.
Enhanced Medication Safety: Mandatory medication safety training and structured handoff protocols will ensure staff are well-equipped to handle high-alert medications and medication reconciliation, reducing medication errors.
Reduced Staff Fatigue: Addressing staffing issues through revised nurse-patient ratios, shift limitations, and mandatory rest periods will help alleviate staff fatigue, leading to better focus and decision-making during patient care.
Minimized Distractions: Establishing quiet zones for handoffs will create a distraction-free environment, ensuring clear and focused communication and improving the quality of care provided during these critical times.

Rough Timeline:

Month 1-2: Develop and approve policies for structured handoffs, medication safety training, staffing regulations, and quiet zones. Begin designing the quiet zone areas and identifying staff for the training program.
Months 3-4: All clinical staff will be required to undergo mandatory training on handoff protocols and medication safety. The design and implementation of quiet zones in high-risk areas like the ICU will also be finalized.
Months 5-6: Implement new staffing policies, including nurse-patient ratio adjustments and shift limits. Monitor the effectiveness of the quiet zones and adjust environmental factors as necessary.
Month 6-12: Complete the full rollout of training and policies. Conduct regular evaluations and audits to ensure adherence to protocols, and gather feedback from staff to refine processes.

These changes should lead to measurable improvements in communication accuracy, medication safety, staff well-being, and overall patient care quality by the end of the first year.

Existing Organizational Resources

Identify resources that may need to be obtained for the safety improvement plan’s success. Consider what existing resources may be leveraged to enhance the improvement plan.

Several key resources will be essential to ensure the success of the safety improvement plan. First, comprehensive training materials must be developed or purchased, particularly for standardized handoff protocols and medication safety. The hospital’s existing nursing staff and educational resources can be leveraged to facilitate training, with content being distributed through the current Learning Management System (LMS) to ensure all clinical staff receive consistent and efficient education. Additionally, staffing resources may need to be adjusted to meet optimal nurse-patient ratios, which could involve hiring temporary or part-time staff to prevent fatigue and support adequate staffing during shift changes. Current scheduling software can ensure that shifts are balanced and staffing meets the department’s needs.

Secondly, environmental modifications will be necessary to reduce distractions during shift changes. This may include the creation of quiet zones in high-risk areas like the ICU, which could involve minor renovations or repurposing existing spaces. The hospital’s facilities management team can assist with these changes. Additionally, monitoring and evaluation tools will be needed to assess the effectiveness of the new protocols, such as patient safety reporting systems and audit tools for handoff documentation. Existing quality improvement teams and patient safety reporting systems can be leveraged to track the plan’s success and ensure that necessary adjustments are made as the plan is implemented. When effectively obtained and utilized, these resources will significantly enhance the hospital’s ability to reduce safety risks and improve patient care.

References:

Abraham, J., Meng, A., Sona, C., Wildes, T., Avidan, M., & Kannampallil, T. (2021). An observational study of postoperative handoff standardization failures. International Journal of Medical Informatics, 151, 104458. https://doi.org/10.1016/j.ijmedinf.2021.104458

Adam, M. H., Ali, H. A., Koko, A., Ibrahim, M. F., Omar, R. S., Mahmoud, D. S., Mohammed, S. O. A., Ahmed, R. A., Habib, K. R., & Ali, D. Y. (2022). The situation, background, assessment, and recommendation (SBAR) form is used as a tool for handoff communication in the pediatrics department of a Sudanese teaching hospital. Cureus, 14(11). https://doi.org/10.7759/cureus.31998