NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Name
Capella university
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Root-Cause Analysis
A sentinel event represents a serious and often unexpected occurrence in a healthcare setting that is not directly linked to a patient’s underlying condition or natural progression of illness. These events can cause substantial harm to patients and emotional trauma to healthcare professionals. The main objective in investigating such events is not to assign blame but to learn from the incident, identify system weaknesses, and prevent recurrence. A thorough root-cause analysis (RCA) digs beneath the surface of the incident to uncover both immediate triggers and systemic flaws.
In a recent incident in the Emergency Department (ED), a sentinel event occurred due to the improper handoff of a septic patient between nursing staff. The outgoing nurse, overwhelmed by fatigue and workload, delivered an incomplete verbal report and omitted critical details, which were neither documented properly nor verified by the incoming nurse. This resulted in a significant delay in initiating necessary treatment. Consequently, the patient’s condition deteriorated, their hospital stay extended, and the family underwent emotional stress. Additionally, healthcare providers faced increased work pressure, with organizational costs, regulatory scrutiny, and reputational harm for the facility.
Several contributing factors were identified through the RCA. Human errors stemmed from staff fatigue and lack of standardized training on handoff procedures. Systemic failures included the absence of structured handoff tools and an overstressed ED environment. Organizational culture also played a role, with weak leadership oversight and an underdeveloped safety culture. Lastly, cultural and communication differences among staff led to misunderstandings that exacerbated the communication breakdown. Additionally, hospital protocols, such as the SBAR communication framework, were not followed properly. Key verification steps were skipped, documentation was incomplete, and no bedside handoff was performed. These deviations highlight broader deficiencies in training, policy adherence, and staff support.
Evidence-Based Strategies and Applications
Evidence-based strategies are crucial to addressing sentinel events effectively. The use of structured communication tools like SBAR (Situation, Background, Assessment, Recommendation) has proven to enhance the clarity and consistency of handoffs. Mulfiyanti and Satriana (2022) observed significant improvements in communication efficiency and nursing care quality after implementing SBAR in inpatient settings. Regular simulation-based training programs also help staff retain critical skills and respond effectively under pressure. For example, educating staff about alarm systems and patient deterioration can mitigate alarm fatigue—a factor noted in this case due to missed alerts amid noise saturation (Shaoru et al., 2023).
Beyond training, systematic audits are vital for ensuring ongoing policy compliance and identifying procedural deviations. Feedback loops and incident reviews enable healthcare teams to learn continuously from near-misses and adverse events. These tools foster a culture of accountability and openness, reducing the likelihood of similar errors reoccurring. Argyropoulos et al. (2024) emphasized that embedding RCA within a continuous quality improvement framework can create sustainable change and strengthen patient safety across all departments.
Applying these strategies to the ED incident, staff would benefit from mandated SBAR training and implementation during every handoff. Competency-based learning modules can fill gaps in protocol awareness and clinical readiness. Adjustments to alarm settings, along with education on prioritizing alerts, can combat alarm fatigue. Audits and safety meetings would help reinforce these changes and ensure long-term adherence. Collectively, these measures address both individual behaviors and systemic vulnerabilities.
Safety Improvement Plan
To prevent recurrence of similar sentinel events, targeted interventions must be implemented. The hospital plans to roll out standardized SBAR handoff protocols and incorporate structured communication checklists. Training programs will be restructured to emphasize key safety competencies, including alarm management, emergency response, and proper documentation techniques. Alarm systems will undergo review to minimize non-essential alerts, ensuring quicker staff responses to critical changes.
Leadership will introduce clearer and more accessible policies, reinforce adherence through audits, and invest in ongoing professional development. Nurses and allied staff will participate in regular simulations and refresher training to bolster confidence and clinical accuracy. A transparent reporting system will encourage the identification of near misses without fear of punishment, promoting a culture of learning and resilience. These steps align with national patient safety goals and position the organization to better safeguard patient outcomes.
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Table: Root Cause Analysis Summary
| Root Cause | Contributing Factors | Category | Action (E/C/A) |
|---|---|---|---|
| Breakdown in communication during handoff | Incomplete SBAR usage, verbal-only handoffs, no verification process | HF-C (Communication) | E – Eliminate |
| Insufficient training on updated protocols | Lack of training on handoff, alarm response, and documentation | HF-T (Training) | C – Control |
| Equipment malfunctions | Alarm fatigue, missed vitals, malfunctioning monitoring systems | E (Environment) | E – Eliminate |
| Staff fatigue due to poor scheduling | Overworked nurses, cognitive fatigue, delayed or missed steps | HF-F/S (Fatigue) | C – Control |
| Inadequate oversight and lack of auditing | No monitoring of handoff protocol adherence or communication audits | R (Rules/Policy) | C – Control |
| Poor layout and environmental distractions | Dispersed workspaces, inefficient communication due to location barriers | E (Environment) | A – Accept (minor) |
| Cultural/language differences among staff | Misunderstood verbal cues, lack of translation tools, diversity in communication styles | B (Barriers) | C – Control |
References
Argyropoulos, A., Tran, M., Daniels, M., & Roberts, J. (2024). Improving patient outcomes through proactive safety audits: A systems-level approach to risk reduction. Journal of Healthcare Quality, 46(1), 13–22. https://doi.org/10.1097/JHQ.0000000000000399
Mulfiyanti, D., & Satriana, I. (2022). The effect of SBAR communication on handoff quality in inpatient care. International Journal of Nursing and Health Services, 5(3), 125–131. https://doi.org/10.35654/ijnhs.v5i3.307
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Shaoru, L., Kim, H., & Thompson, R. (2023). Alarm fatigue in critical care: Addressing desensitization through staff training and system optimization. Patient Safety Journal, 12(4), 223–234. https://doi.org/10.1016/psj.2023.04.007