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 Understanding the Sentinel Event
A sentinel event is defined as an unforeseen incident that results in serious physical or psychological harm or poses a significant risk of such harm, occurring independently of the patient’s natural disease progression. These events are often distressing for patients and their families and place immense emotional and professional strain on healthcare providers. The fundamental aim of investigating these events is to uncover systemic flaws, learn from the incident, and establish procedures that bolster patient safety.
In a recent case within the Emergency Department (ED), a sentinel event occurred due to ineffective communication during a patient handoff involving a septic individual. The outgoing nurse, impacted by fatigue and workload stress, failed to convey essential information and did not complete the necessary documentation. This communication breakdown delayed appropriate treatment, worsening the patient’s condition, extending their hospital stay, and necessitating further interventions. The ramifications were widespread—beyond affecting the patient and their family, the incident contributed to staff burnout and increased the institutional burden due to reputational damage, financial strain, and regulatory oversight.
Analysis of this incident revealed multi-layered causes. At the human level, errors stemmed from communication lapses and exhaustion. System-wide, the absence of structured electronic handoff tools and inefficient workflow processes hindered effective care delivery. Additionally, cultural and organizational gaps—such as inadequate training and lack of policy enforcement—were evident. Together, these factors underscore the necessity for comprehensive improvements in communication systems, staff education, and leadership involvement to ensure safer care environments.
Key Findings and Contributing Factors
Root-cause analysis (RCA) identified numerous contributing elements, ranging from individual oversights to systemic inadequacies. The SBAR (Situation, Background, Assessment, Recommendation) communication framework, although in place, was not properly applied. An incomplete verbal report and the lack of a formal bedside handoff led to gaps in critical patient information exchange. Furthermore, essential documentation was either lacking or incomplete, ultimately resulting in missed clinical interventions and elevated patient risk.
Organizationally, several shortcomings were exposed. Leadership did not consistently enforce handoff standards, and staff faced obstacles accessing updated procedural protocols. These challenges were intensified by staffing shortages, which led to cognitive overload and increased the likelihood of errors. Environmental issues such as disorganized ED layout and malfunctioning equipment further disrupted timely decision-making and recognition of clinical deterioration.
Communication failures were not limited to nurses alone. Physicians’ updates, including critical medication orders, were not efficiently relayed, and communication with patients and families remained inadequate. These lapses highlighted a broader communication deficit, emphasizing the need for validated, cross-disciplinary, and well-documented exchanges during patient transitions.
Table 1: Root Causes and Contributing Factors
| Root Cause | Contributing Factors | HF-C | HF-T | HF-F/S | E | R | B |
|---|---|---|---|---|---|---|---|
| Communication breakdown in care team | Misinterpretation of patient condition | ✔ | |||||
| Insufficient training | Missed critical care changes | ✔ | |||||
| Equipment issues | Missed warning signs | ✔ | |||||
| Staff fatigue | Compromised clinical judgment | ✔ | |||||
| Protocol noncompliance | Omitted interventions | ✔ | |||||
| Organizational barriers | Ineffective communication channels | ✔ | ✔ |
Key: HF-C = Human Factor – Communication; HF-T = Human Factor – Training; HF-F/S = Human Factor – Fatigue/Scheduling; E = Environment/Equipment; R = Rules/Policies; B = Barriers
Solutions and Safety Improvement Plan
To mitigate future risks, several evidence-based solutions were proposed. A primary recommendation involves the full implementation of the SBAR framework for all patient handoffs. Research supports SBAR as a reliable method for enhancing nurse communication efficiency and reducing patient safety risks (Mulfiyanti & Satriana, 2022). Additionally, comprehensive training focused on emergency equipment usage and alarm management will be introduced to address both skill deficits and alarm fatigue.
Routine audits and structured feedback mechanisms will serve as continuous quality improvement tools. These initiatives will help track compliance, evaluate performance, and reinforce accountability. Argyropoulos et al. (2024) emphasize the value of such data-driven assessments in cultivating a strong safety culture. Simulation-based training will further ensure staff preparedness for high-stakes scenarios, as supported by findings from Shaoru et al. (2023).
To support these strategies, leadership will mandate standardized communication protocols, integrate real-time safety dashboards, and initiate quarterly performance reviews. The combined effect of these interventions is expected to elevate care quality, strengthen patient safety, and promote a culture of transparency and continual improvement.
Table 2: Safety Improvement Action Plan
| Issue | Action Plan | Type (E = Eliminate, C = Control, A = Accept) |
|---|---|---|
| Communication Breakdown | Implement SBAR for all handoffs | E |
| Inadequate Training | Provide emergency training and regular refreshers | E/C |
| Alarm Fatigue | Adjust alarm settings and minimize non-essential alerts | E |
New Policies and Professional Development Initiatives
- Standardized Handoff Protocols: The SBAR model will become a mandatory part of patient transfer, coupled with compulsory bedside reporting. Staff will undergo assessments to ensure consistent usage of this framework.
- Enhanced Staff Education: Competency-based education will be introduced during onboarding and maintained through periodic refresher courses. Training will cover emergency procedures, communication strategies, and equipment handling.
- Alarm System Optimization: A thorough evaluation of the ED’s alarm infrastructure will be conducted to minimize false alarms and prioritize critical alerts. Staff training will focus on interpreting and responding to alarms effectively.
- Safety Audits and Feedback: Monthly audits and quarterly feedback sessions will be implemented to measure adherence to protocols and address areas needing improvement. This cycle of evaluation and reinforcement will drive sustainable safety practices.
Collectively, these initiatives aim to decrease avoidable harm, support a proactive patient safety culture, and empower healthcare professionals through training, structured communication, and leadership engagement.
References
Argyropoulos, G. V., Miller, M., & Kapadia, P. (2024). Root cause analysis and continuous improvement in healthcare: A systematic approach. Journal of Patient Safety and Risk Management, 29(1), 33–41.
Mulfiyanti, N., & Satriana, Y. (2022). Implementation of SBAR Communication Techniques to Improve Nurse Handoff Efficiency in Tabanan Hospital. International Journal of Health Sciences, 6(2), 109–117.
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Shaoru, L., Wang, Z., & Chen, F. (2023). Simulation-based learning and alarm system optimization to mitigate alarm fatigue in critical care. Healthcare Technology Letters, 10(4), 215–220.
