Capella 4035 Assessment 2

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

Understanding the Incident

Sentinel events are critical occurrences in healthcare that signify a breakdown in patient safety, often unrelated to the patient’s medical condition. Such incidents can result in severe outcomes for patients, emotional distress for families, and professional setbacks for healthcare staff. Root-cause analysis (RCA) is employed to investigate these events thoroughly, aiming to identify both the immediate and systemic failures that contributed to them. By understanding these factors, healthcare facilities can implement targeted interventions to mitigate future risks.

A particular case involved a patient presenting to the Emergency Department (ED) in septic shock. Significant treatment delays occurred due to inadequate handoff during a nursing shift change. The outgoing nurse failed to convey essential clinical updates, and documentation was insufficient. As a result, the patient’s condition worsened, requiring an extended hospital stay and additional medical interventions. This case exposed the emotional and professional impact on the healthcare team and underscored systemic gaps in communication protocols and oversight.

Analyzing Contributing Factors

Root Causes and Contributing Elements

The RCA revealed several underlying issues. Human factors such as staff exhaustion, inconsistent communication, and inadequate training on structured handoffs were primary contributors. Dependence on verbal exchanges without written documentation heightened the risk of misinformation. Additionally, the ED’s disorganized layout, insufficient digital handoff tools, and workforce shortages further disrupted the care continuum.

Cultural and linguistic differences among team members compounded the problem, especially in a setting lacking standardized communication training. Moreover, the organizational culture failed to reinforce the importance of handoff protocols, and leadership did not routinely audit compliance. These elements pointed to a breakdown in environmental design, training initiatives, and leadership engagement.

Deviation from Standards

The standardized SBAR (Situation, Background, Assessment, Recommendation) handoff format was not effectively utilized. The outgoing nurse provided an incomplete verbal report, and the receiving nurse did not seek additional details. Critical elements of the patient’s condition and care plan were omitted from documentation, representing a clear deviation from protocol.

Roles, Communication, and Environment

Personnel Involved

The core individuals implicated included the two nurses handling the shift transition and the attending physician, who made care adjustments without ensuring they were clearly communicated. The charge nurse failed to uphold adherence to handoff protocols, and administrative supervision was absent during this critical period.

Communication Breakdown

There were clear communication gaps both among the nursing staff and between nurses and physicians. The lack of updates regarding the patient’s deteriorating condition resulted in compromised care. Additionally, the patient and their family were not included in the communication loop, limiting informed consent and engagement in care decisions.

Environmental and Staffing Constraints

The emergency department’s physical design—with isolated nurse stations and malfunctioning equipment—created barriers to effective communication and timely monitoring. Staffing shortages further strained the system, leading to missed assessments and increased workload for available staff. Although nurses were clinically competent, they lacked specific training for managing high-acuity patients and complex medication regimens.

Organizational and Monitoring Shortfalls

Policy Implementation Issues

Handoff and medication safety policies existed but were inconsistently applied due to their complexity and inaccessibility. This led to variability in execution across shifts, reducing policy effectiveness.

Monitoring Failures

Vital signs were not continuously observed during critical periods, and alarm fatigue caused essential alerts to be overlooked. The volume of non-urgent alarms desensitized staff, reducing their responsiveness to critical warnings. These shortcomings indicate deficiencies in monitoring systems and alarm management protocols.

Recommendations and Safety Enhancements

Lessons and Improvement

To avoid similar occurrences in the future, systemic improvements must be made. Enforcing the consistent use of SBAR for all shift transitions is critical. Staff should be trained in effective communication and encouraged to engage in open dialogue. Incorporating digital systems for handoffs and real-time patient monitoring can help reduce human error and streamline care coordination.

Patient Safety Measures

Improving safety requires installing automated alerts for unstable patients, conducting regular simulation drills, and optimizing alarm systems to reduce fatigue. Additionally, implementing a non-punitive, feedback-driven incident reporting system can cultivate a culture of continuous learning and improvement.

Root Cause(s) and Contributing Factors

Factor Category	Identified Issue	Classification Code
Communication Breakdown	Omission of essential patient information during shift handoff	HF-C (Human Factor – Communication)
Training Deficiencies	Lack of updated training on handoff protocols	HF-T (Human Factor – Training)
Equipment Malfunction	Faulty alarms failed to alert staff about patient decline	E (Environment/Equipment)
Staff Fatigue	Extended work hours affected performance and alertness	HF-F/S (Human Factor – Fatigue/Scheduling)
Policy Non-Adherence	Inconsistent adherence to existing safety policies	R (Rules/Policies/Procedures)
Communication Infrastructure	Lack of digital platforms for structured handoff communication	B (Barriers)

Application of Evidence-Based Strategies

Intervention	Strategy	Supporting Evidence
Structured Communication	Standardize SBAR for shift handoffs	Mulfiyanti & Satriana (2022)
Simulation-Based Training	Provide regular emergency simulations and refresher training	Shaoru et al. (2023)
Alarm Optimization	Refine alarms to minimize desensitization and improve response	Shaoru et al. (2023)
Routine Audits and Feedback	Conduct regular reviews and implement feedback loops	Argyropoulos et al. (2024)

Safety Improvement Plan

Root Cause	Planned Action	Timeline
Communication Failures	Enforce SBAR communication for all clinical transitions	Initiate in 1–2 months
Training Gaps	Launch structured onboarding and simulation-based education	Begin within 3 months
Alarm Desensitization	Adjust alarm systems and conduct focused training	Implement over 3–6 months
Policy Non-Adherence	Develop simplified and easily accessible policy guidelines	Complete in 3 months

Existing Organizational Resources

Resources Available	Resources Needed
Skilled senior staff for guidance	Specialized training in SBAR and alarm management
EHR platform to support communication	Enhanced patient monitoring tools and real-time analytics
Multidisciplinary safety committees	Dedicated funding for education and system upgrades

References

Argyropoulos, C. D., Obasi, I. C., Akinwande, D. V., & Ile, C. M. (2024). The impact of interventions on health, safety and environment in the process industry. Heliyon, 10(1), e23604–e23604. https://www.sciencedirect.com/science/article/pii/S2405844023108127

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275