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

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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

1. Understanding the Sentinel Event

A sentinel event is a critical, unexpected patient safety incident not associated with the natural progression of a patient’s condition. These events can have profound consequences, not only for the patient but also for the healthcare staff and the institution. One such event involved a 56-year-old woman admitted for acute heart failure (AHF). A communication failure during the nursing handoff between shifts contributed significantly to the patient’s deterioration. The outgoing nurse neglected to document and communicate recent critical changes in the patient’s condition—such as a 5-pound weight gain, increased blood pressure, and signs of fluid retention—due to time pressure and staff shortage. As a result, the incoming nurse was unaware of these clinical indicators and failed to monitor the patient’s vital signs appropriately. This oversight led to a severe episode of acute pulmonary edema, requiring urgent intervention, including intravenous diuretics and non-invasive ventilation.

This breakdown had a ripple effect. The patient endured a delayed recovery and unnecessary suffering, while her family experienced emotional stress. The staff involved faced professional scrutiny and emotional trauma. The hospital also suffered reputational and financial consequences. According to Nawawi and Ibrahim (2024), approximately 40.1% of adverse events tied to communication gaps arise from inadequate handoff practices, often resulting in increased complications, extended hospital stays, and even mortality.

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

A root-cause analysis (RCA) revealed that this event stemmed from a complex interplay of human, system, and organizational factors. Human elements included the failure to document and verbally share essential patient information. Nurse fatigue from long shifts and an overburdened workload also contributed to distracted and incomplete care transitions. System-related issues included a lack of standardized handoff protocols and insufficient EHR tools to ensure continuity of care. The organizational culture lacked a strong emphasis on patient safety and communication, further contributing to the failure. Moreover, cultural and language differences among staff may have complicated communication, limiting clarity during the exchange of critical data.

The situation also involved non-adherence to institutional protocols. The staff did not fully comply with the facility’s handoff guidelines. There were clear lapses in documentation, with crucial clinical updates such as elevated blood pressure and diuretic changes being overlooked. The oral exchange of information was incomplete and undocumented. As Minagorre et al. (2023) emphasize, verbal communication during handoff must occur face-to-face and be supplemented by thorough documentation to ensure continuity of care.

The individuals involved included the outgoing and receiving nurses, a prescribing physician, and supervisory staff. The departing nurse did not communicate the patient’s updated condition, and the receiving nurse did not seek clarification. The physician had updated the treatment plan, but due to communication lapses, these changes were not relayed. Supervisors failed to verify protocol compliance and did not provide adequate training on structured communication tools like SBAR. This multilayered failure underscores the necessity of a systematic approach to patient safety and team communication.

2. Contributing Factors and Communication Breakdown

A significant element contributing to this adverse event was the breakdown in interdisciplinary and patient-provider communication. The nurses involved failed to exchange comprehensive information, including updates to medication and vital sign trends. The physician’s modified treatment plan, which included IV diuretics, was not effectively communicated to the incoming nurse, leading to delayed intervention. Furthermore, the patient was not adequately informed about her care progression, undermining her understanding of the treatment plan. According to Minagorre et al. (2023), clear and direct communication is essential during transitions of care to avoid medication errors and enhance patient outcomes.

Several physical, staffing, and training-related factors further influenced the situation. The hospital’s layout, including shared workstations in high-traffic zones, impeded private, focused communication and documentation. The handoff occurred far from the patient’s bedside, removing the opportunity for real-time information sharing. This environmental chaos delayed data input into the EHR, making it difficult for the incoming nurse to review the patient’s recent clinical changes.

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

Staffing shortages played a critical role. Nurses were stretched thin with long shifts, leading to fatigue, which in turn contributed to oversight and incomplete handoffs. Research shows that excessive workload increases the risk of errors in data handling and communication (Minagorre et al., 2023). Furthermore, although the nurses were clinically competent, their limited training in structured handoff processes, like SBAR, led to gaps in patient safety. Ongoing education on communication protocols is essential to support nurse confidence and accuracy in care transitions (Nawawi & Ibrahim, 2024).

Below is a table summarizing the contributing factors to this sentinel event:

Category	Specific Issues Identified
Physical Environment	Busy centralized stations, distant from patient rooms, hindered effective communication.
Staffing Levels	Inadequate nurse-to-patient ratio; fatigue from long shifts contributed to errors.
Training & Competency	Lack of training in SBAR; unfamiliarity with handoff protocol led to incomplete communication.

Organizational factors also played a part. Policy compliance was inconsistent; even though handoff guidelines existed, they were vague, poorly disseminated, and difficult to access. Staff were unaware of revisions and uncertain about documentation procedures. This lack of policy clarity resulted in incomplete transitions, with missed opportunities to confirm medication orders or review symptom changes. A culture of blame may have further discouraged staff from raising concerns about procedural lapses.

3. Policy Review and Improvement Plan

The policy and procedural framework within the hospital revealed several shortcomings. Despite the existence of formal handoff policies, they were not consistently followed. Critical steps such as double-checking medication changes or documenting patient progress in the EHR were missed. The handoff was informal and lacked verification mechanisms to ensure information transfer accuracy. This deviation from protocol facilitated the adverse outcome, highlighting the importance of process audits and accountability measures.

Moreover, the clarity of existing policies was insufficient. Staff struggled to identify the most current versions of guidelines and often interpreted them differently. The lack of accessible, concise policy documents limited compliance and consistency. Institutions must prioritize the regular updating and dissemination of clinical protocols to prevent confusion during critical transitions.

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

Improving policy compliance requires a multifaceted strategy. Training programs should focus on reinforcing standardized communication tools like SBAR, providing simulations of effective handoffs, and fostering a culture where staff feel empowered to clarify and question unclear information. Additionally, leadership must emphasize safety by modeling structured communication, regularly auditing handoff processes, and encouraging open dialogue about challenges.

To reinforce improvements, the following safety enhancement strategies are recommended:

Improvement Strategy	Action Plan
Standardized Handoff Protocol	Mandate SBAR-based verbal and written handoffs; integrate with EHR templates.
Staff Education and Simulation	Provide ongoing training and role-play scenarios for effective communication.
Leadership Accountability	Ensure supervisors audit compliance and provide feedback during shift changes.
Environmental Optimization	Establish dedicated handoff zones close to patient rooms with minimal disruption.
Policy Access and Clarity	Consolidate and distribute clear, up-to-date handoff guidelines electronically.

Creating a culture of safety involves more than implementing rules—it requires engaging staff, ensuring accountability, and continuously improving through feedback and analysis. Preventing sentinel events depends on an organization’s ability to learn from its failures and commit to safer, more transparent practices.

References

Minagorre, D. M., López, P. R., Jiménez, J. S., & Martínez, M. F. (2023). Safe communication practices in nursing handoffs: An integrative review. Journal of Nursing Management, 31(4), 733–741. https://doi.org/10.1111/jonm.13728

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

Nawawi, N. M., & Ibrahim, R. (2024). Improving nursing handover with SBAR: A critical review. International Journal of Nursing Studies, 141, 104560. https://doi.org/10.1016/j.ijnurstu.2023.104560