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

NURS FPX 4035 Assignment 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 are serious, often unexpected occurrences in healthcare settings that result in death, serious injury, or present a substantial risk thereof. These incidents impact not only patients and their families but also create distress for healthcare professionals involved. Such events present critical opportunities for healthcare institutions to learn and grow. Root-cause analysis (RCA) enables the identification of both immediate errors and deeper systemic weaknesses. These analyses foster protocol revisions and promote a safety-centric culture that minimizes the recurrence of such events.

In the sentinel event under review, a patient with sepsis in the Emergency Department (ED) experienced significant care delays due to a breakdown in communication during a nurse shift handoff. Key patient information was omitted during the verbal transition, and the electronic documentation was insufficient. As a result, the patient’s condition worsened, requiring an extended hospitalization and additional treatments. This situation not only caused emotional distress to the patient’s family but also placed operational stress on staff and institutional resources.

The analysis revealed that several contributing factors were at play, including human elements such as fatigue and ineffective communication, along with systemic challenges like inefficient workflow and poor environmental design. Organizational culture also influenced the incident due to insufficient prioritization of patient safety, weak policy enforcement, and limited leadership intervention. Furthermore, language barriers among a diverse staff may have exacerbated the miscommunication during care transitions.

Communication and Protocol Deviation

The core of the incident stemmed from a deviation from the hospital’s standard handoff protocol, specifically the SBAR (Situation, Background, Assessment, Recommendation) tool. The nurse ending their shift failed to communicate the patient’s deteriorating condition thoroughly, while the incoming nurse did not validate or clarify the incomplete handoff. A bedside exchange of information was not conducted, and critical patient data were missing from the electronic health records. These oversights led to missed early intervention opportunities. Additionally, supervisory staff did not enforce the SBAR process or perform routine checks to monitor adherence.

Breakdowns in interdisciplinary communication further contributed to care delays. For example, medication orders issued by physicians were not clearly conveyed to the nursing team. Simultaneously, the patient and their family were left uninformed about treatment updates, limiting their ability to engage meaningfully in healthcare decisions. These multilayered communication gaps indicate a need for a comprehensive strategy to enhance interprofessional collaboration and patient engagement.

Environmental challenges also played a role. The ED’s physical layout hindered efficient communication, with staff stations located far from patient rooms. Equipment malfunctions and recurring false alarms added to the complexity, creating alarm fatigue and desensitization to alerts. Additionally, inadequate staffing created a high-pressure environment where nurses struggled to balance responsibilities, resulting in task omissions and compromised care quality. Many staff lacked recent training on equipment use and standardized handoff practices.

The following table outlines the identified root causes and contributing factors using standardized categories:

Table 1: Root Causes and Contributing Factors

Root Cause / Contributing Factor	Category Code	Explanation
Communication breakdown among healthcare providers	HF-C (Human Factor – Communication)	Incomplete and unverified handoff led to missed care interventions.
Lack of training on protocols and handoff tools	HF-T (Human Factor – Training)	Staff were not regularly trained on SBAR or alarm response protocols.
Malfunctioning equipment and layout delays	E (Environment/Equipment)	Technology issues and poor spatial design disrupted response efficiency.
Nurse fatigue from understaffing and poor scheduling	HF-F/S (Human Factor – Fatigue/Scheduling)	Staff exhaustion contributed to care omissions and slower response times.
Non-adherence to established safety protocols	R (Rules/Policies/Procedures)	Staff failed to follow SBAR protocols consistently; audits were not enforced.
Poor organizational oversight and culture	B (Barriers)	Leadership failed to monitor compliance or intervene in unsafe practices.

Evidence-Based Strategies and Safety Improvement Plan

Implementing evidence-based strategies is essential to mitigate the recurrence of sentinel events. The use of structured communication frameworks, comprehensive staff training, and regular protocol audits are core strategies in improving patient safety. Research shows that SBAR communication enhances clarity during handoffs and improves treatment continuity (Mulfiyanti & Satriana, 2022). Simulation-based training allows healthcare professionals to rehearse critical situations and refine the use of medical technology, increasing response effectiveness (Shaoru et al., 2023). Moreover, root-cause analysis (RCA) systems support continuous learning and adaptive safety cultures (Argyropoulos et al., 2024).

Institutions must incorporate SBAR protocols as mandatory during all transitions in patient care. Staff should receive regular, hands-on training for effective communication, emergency management, and use of medical equipment. Alarm systems should be optimized to reduce unnecessary notifications and focus on high-priority alerts. Additionally, leadership should implement routine safety audits and feedback loops to monitor protocol adherence and foster accountability. These strategies require collaboration across disciplines to ensure sustainable improvement in care quality.

Table 2: Safety Strategies and Their Applications

Evidence-Based Strategy	Application
SBAR Communication Tool	Standardizes patient handoff to reduce miscommunication and omitted details.
Simulation-Based Training	Enhances preparedness for emergencies and improves use of medical technology.
Alarm System Optimization	Minimizes false alerts to help staff prioritize critical patient needs.
Safety Audits and Feedback Loops	Identifies protocol deviations and supports a proactive improvement culture.

To solidify the institutional response, an action plan has been developed, aligning specific interventions with each identified issue:

Table 3: Safety Improvement Action Plan

Issue Identified	Action Plan	E / C / A
Communication Breakdown	Enforce SBAR with mandatory checklist verification during all patient handoffs.	E
Inadequate Training	Introduce onboarding and biannual training on protocols and equipment.	E/C
Alarm Fatigue	Recalibrate alarm thresholds and train staff to identify priority alerts.	E
Equipment Failures	Schedule preventive maintenance and replace malfunctioning systems.	E
Nurse Fatigue	Modify scheduling practices and increase staffing to reduce burnout.	C
Policy Non-Adherence	Provide centralized access to policies and perform audits for compliance.	C

To reinforce these strategies, key enhancements in policy and process design will be adopted. SBAR protocols will be integrated directly into electronic health records for seamless documentation. Scenario-based emergency drills will be conducted quarterly to strengthen staff readiness. Workshops on alarm management will help staff reduce alarm fatigue and focus on critical alerts. Policy access will be streamlined through a centralized digital platform. Finally, leadership teams will conduct monthly safety audits and implement performance improvement plans based on findings. Collectively, these reforms aim to create a resilient, high-reliability healthcare organization rooted in safety, accountability, and continuous improvement.

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 Assignment 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.