Capella 4035 Assessment 2

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Root-Cause Analysis and Understanding the Incident

Sentinel events represent significant failures in healthcare delivery, unrelated to the patient’s original medical condition, which often result in grave consequences. These incidents can inflict psychological trauma on families and negatively affect healthcare professionals. To uncover both immediate and systemic causes, healthcare facilities employ Root-Cause Analysis (RCA). This method enables the identification of system vulnerabilities and supports the creation of strategies that reduce the likelihood of recurrence.

A recent sentinel event involved a patient admitted to the Emergency Department (ED) in septic shock. A breakdown occurred during a nursing handoff when critical patient information was neither documented nor communicated properly. The failure in the transition of care led to a worsening of the patient’s condition, extended hospitalization, and complex treatment. The event underscored emotional strain among the clinical team and pointed to systemic communication and policy deficiencies within the institution.

Key Factors and Deviations from Standards

The RCA revealed multiple contributing issues, particularly human factors like fatigue, vague communication, and lack of proper training in standardized handoffs. A reliance on verbal communication without sufficient written support increased the risk of errors. Environmental challenges such as a disorganized ED layout, absence of digital handoff tools, and insufficient staffing contributed further to lapses in patient care.

Language and cultural differences among the staff, coupled with an absence of standard communication training, compounded these issues. The organization had handoff protocols in place, but their significance was neither emphasized nor routinely monitored by leadership, exposing gaps in accountability, system oversight, and staff preparedness.

The handoff communication model SBAR (Situation, Background, Assessment, Recommendation) was not followed. The outgoing nurse omitted critical updates, and the receiving nurse failed to clarify them. This deviation from established practice led to an incomplete understanding of the patient’s condition, violating expected protocols and contributing to suboptimal outcomes.

Communication Breakdown, Roles, and Environmental Challenges

Personnel and Communication Gaps

The event involved two primary nurses during shift change, the attending physician, and the charge nurse. While the physician revised the treatment plan, they did not ensure that the changes were communicated effectively. The charge nurse also failed to enforce protocol adherence, and a lack of administrative presence at the time allowed protocol violations to go unchecked.

Communication lapses between nurses and the physician led to an inadequate understanding of the patient’s worsening state. Additionally, the patient and family were not kept adequately informed, limiting their engagement in decision-making and care planning. These failures underscored the breakdown in both intra-professional and patient-provider communication.

Environmental Constraints and Staffing Limitations

The ED’s disjointed physical setup and technical issues hindered monitoring and timely intervention. Equipment failures and staffing shortages placed undue pressure on the team. Despite clinical competency, the staff lacked focused training in handling high-acuity patients and complex medications, increasing the potential for missteps in patient management.

Organizational Shortcomings and Monitoring Deficits

While safety policies were available, they were overly complex and inconsistently applied. Staff unfamiliarity with protocols led to inconsistent practices across different shifts. Alarm fatigue was another major concern; frequent non-urgent alerts desensitized the staff, resulting in delayed responses to critical alarms. These failures reflected inadequate alarm system configuration and a lack of proactive monitoring processes.

Recommendations and Safety Improvement Plan

Improvement Strategies and Interventions

To address the root causes and enhance patient safety, systemic improvements are essential. Consistent use of SBAR during every handoff should be mandated. Staff must receive structured training focusing on communication, emergency simulations, and error recognition. Emphasizing a culture of transparency and accountability will support safe practice.

Digital tools should be integrated to facilitate structured handoffs and real-time updates. Alarm systems must be optimized to minimize false alerts and ensure that critical alarms receive immediate attention. Encouraging staff to report safety concerns without fear of punishment can further enhance learning and improvement.

Root Causes and Contributing Factors

Factor Category	Identified Issue	Classification Code
Communication Breakdown	Failure to convey critical patient updates during handoff	HF-C (Human Factor – Communication)
Training Deficiencies	Inadequate training on handoff best practices	HF-T (Human Factor – Training)
Equipment Malfunction	Alarm systems failed to alert staff of deterioration	E (Environment/Equipment)
Staff Fatigue	Long shifts affected performance and attention	HF-F/S (Human Factor – Fatigue/Scheduling)
Policy Non-Adherence	Inconsistent application of safety protocols	R (Rules/Policies/Procedures)
Communication Infrastructure	Lack of structured digital communication tools	B (Barriers)

Application of Evidence-Based Strategies

Intervention	Strategy	Supporting Evidence
Structured Communication	Standardize SBAR for clinical handoffs	Mulfiyanti & Satriana (2022)
Simulation-Based Training	Conduct frequent emergency and handoff simulations	Shaoru et al. (2023)
Alarm Optimization	Recalibrate alarms to prioritize urgent notifications	Shaoru et al. (2023)
Routine Audits and Feedback	Implement continuous monitoring and responsive feedback	Argyropoulos et al. (2024)

Safety Improvement Plan

Root Cause	Planned Action	Timeline
Communication Failures	Mandate SBAR for every nurse shift handoff	Initiate in 1–2 months
Training Gaps	Launch structured onboarding and emergency simulations	Begin within 3 months
Alarm Desensitization	Update alarm protocols and conduct training	Implement over 3–6 months
Policy Non-Adherence	Revise, simplify, and digitize safety protocols	Complete in 3 months

Existing Organizational Resources and Requirements

Resources Available	Resources Needed
Experienced clinical educators	Tailored training in SBAR and alarm management
EHR system supporting interdepartmental communication	Real-time monitoring systems and intelligent alerting technologies
Safety and quality improvement committees	Budget allocation for staff development and digital infrastructure

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