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

1. Was there a deviation from protocols or standards?:
   • Procedures and Policies: Determine if established protocols were followed or if there were deviations.
   • Were there any steps that were not taken or did not happen as intended?
   • Documentation: Review medical records, nursing notes, and other relevant documentation.

• The hospital’s standardized handoff protocol, including the SBAR (Situation, Background, Assessment, Recommendation) framework, was not fully followed. The outgoing nurse provided an incomplete verbal report without ensuring that all critical patient information was transferred. Additionally, there was no structured verification process to confirm understanding.
• Key steps, such as double-checking medication orders and confirming outstanding care needs, were missed. The receiving nurse did not ask clarifying questions, assuming all relevant details were covered. A formal bedside handoff was not conducted.
• Medical records lacked thorough documentation of the patient’s current condition and pending interventions. Nursing notes were incomplete, missing essential details about recent assessments and medication administration. This gap in documentation led to delays in necessary care.

1. Who was involved?:
   • Staff: Identify the roles of individuals directly involved in the event.
   • Supervisors and Managers: Investigate

The primary individuals involved were the outgoing and incoming nurses responsible for patient handoff. The outgoing nurse failed to provide a complete report, while the incoming nurse did not verify critical patient information. Additionally, a physician had placed new medication orders, but these were not effectively communicated.

Supervisors and Managers:

The charge nurse and unit supervisor were responsible for overseeing shift transitions but did not intervene to ensure adherence to standardized handoff procedures. Nurse managers had not reinforced training on structured communication tools like SBAR. Leadership failed to conduct routine audits to identify gaps in the handoff process. Their lack of oversight contributed to the breakdown in communication and patient safety.

1. Was there a breakdown in communication?:
   • Interdisciplinary Communication: Assess how well different teams communicated.
   • Patient-Provider Communication: Explore whether patients were informed and understood their care.

Yes, there was a breakdown in communication between the nursing staff and the medical team. The outgoing nurse failed to properly hand over critical information, including changes in medication orders, to the incoming nurse. Additionally, the physician’s new medication orders were not communicated clearly to the nursing staff, resulting in delays and potential risks for the patient.

Patient-Provider Communication:

The patient was not adequately informed about their treatment plan or medication changes. Due to the communication failure during the handoff, the patient did not receive a proper explanation of their updated care plan, potentially affecting their understanding of the medications and their treatment expectations.

1. 1. What were the contributing factors?:
      • Physical Environment: Consider facility layout, equipment availability, and workspaces.
      • Staffing Levels: Evaluate if staffing was adequate.

• Training and Competency: Assess staff’s knowledge and skills.

Staffing Levels:
Staffing levels were suboptimal during the event. The unit was understaffed, resulting in nurses being overwhelmed with multiple tasks at once, leading to missed steps in patient care. This overburdening of staff contributed to the breakdown in communication and errors in following protocols.

Training and Competency:
While the nursing staff were generally competent, there were gaps in specific training regarding patient handoff protocols and medication management. Lack of refresher courses and the failure to keep up-to-date with new medication guidelines contributed to errors.

1. Did organizational policies or procedures play a role?:
   • Policy Compliance: Investigate if policies were followed.
   • Policy Clarity: Assess if policies are clear and accessible.

Policy Clarity:
The policies regarding patient handoff and medication administration were in place but lacked clarity and accessibility. Some staff members reported difficulty in locating up-to-date guidelines, which led to confusion and inconsistent application of procedures during the event. This lack of clarity contributed to the incident.

1. Was there a failure in monitoring or surveillance?:
   • Vital Signs Monitoring: Check if there were any missed signs.
   • Alarm Fatigue: Explore if alarms were ignored.

Yes, there was a failure in monitoring vital signs. The patient’s vital signs were not adequately tracked during critical hours, leading to delayed recognition of deteriorating conditions. Nurses failed to document changes in the patient’s status, missing vital clues that could have triggered an earlier intervention.

Alarm Fatigue:
Alarm fatigue was also a factor. Due to the overwhelming number of alarms in the unit, staff became desensitized and failed to respond promptly to important alarms. This contributed to the oversight of critical changes in the patient’s condition, exacerbating the safety risks.

1. What can be learned to prevent recurrence?:
   • Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.
   • Quality Improvement: Consider implementing preventive measures.

Quality Improvement:
Preventive measures like introducing more robust monitoring systems, refining alarm management protocols, and establishing regular training sessions on recognizing patient deterioration are necessary. Incorporating checklists and standardized handoffs can help ensure no critical step is overlooked. Regular audits and feedback loops should be established for continuous quality improvement.

1. 1. How can patient safety be enhanced?:
      • Risk Mitigation: Develop strategies to minimize risks.
      • Education and Training: Ensure staff are well-trained.

• Reporting and Feedback: Encourage open reporting and learning from mistakes.

• To minimize risks, introduce protocols for early detection of patient deterioration and ensure consistent monitoring. Implement fail-safes, like automatic alerts for abnormal vital signs, and regular safety audits to identify potential hazards before they occur.
• Provide ongoing education on the latest clinical guidelines, emergency procedures, and the importance of communication. Simulate high-risk scenarios to improve staff readiness and ensure competency in dealing with complex cases.
• Encourage a non-punitive environment where staff can report errors or near misses without fear of retribution. Regular feedback and analysis of incidents can help identify patterns and guide continuous improvement in care practices.

F/S

Insufficient training on updated protocols, causing staff to miss critical care changes.

Malfunctioning equipment led to missed warning signs and delayed intervention.

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

Training and simulation-based learning are effective in addressing gaps in staff competency. It has been documented that 72%–99% of medical alerts could be false alerts. Regular in-service training on safety protocols, such as the use of medical equipment and handling emergency situations, enhances staff readiness and reduces errors. For example, training on alarm systems and equipment troubleshooting can reduce alarm fatigue and prevent missed alerts (Shaoru et al., 2023).

Systematic safety audits and feedback loops are essential. These mechanisms help identify and address procedural deviations, ensuring adherence to protocols. The literature emphasizes that continuous improvement strategies, such as root-cause analysis and data-driven decision-making, contribute to sustained safety improvements by identifying systemic weaknesses (Argyropoulos et al., 2024).

Conducting systematic safety audits can help identify patterns in sentinel events and potential system flaws. The results from these audits can guide the implementation of more effective safety protocols. Feedback loops will ensure that improvements are sustained, with staff continually learning from near-misses and adverse events. These evidence-based strategies, supported by ongoing evaluation and adaptation, create a proactive safety culture and prevent recurrence of similar incidents.

One for each Root Cause/Contributing Factor from above

Choose one

The timeline for development and implementation is as follows:

Improved Communication Protocol (SBAR):

• Goal: Ensure clear and effective communication during handoffs.
• Timeline: Implement training and protocol changes within 1-2 months.

Staff Competency and Training:

• Goal: Equip staff with the necessary skills and knowledge to follow safety protocols.
• Timeline: Initial training within 3 months, followed by ongoing quarterly updates.

Alarm System Review and Adjustment:

• Goal: Reduce alarm fatigue and prioritize critical alerts to enhance responsiveness.
• Timeline: Full review and system adjustments within 3-4 months, with completion by 6 months.

The plan aims for observable improvements in patient safety and operational efficiency within 6-12 months after implementation.

Staff Expertise: Utilize experienced staff members for training, mentorship, and leadership roles in implementing new protocols.

Technology Infrastructure: Leverage the existing electronic health record (EHR) system to support the new communication protocols and track patient safety metrics.

Current Policies: Use existing safety and quality improvement policies as a foundation for updating and enhancing procedures.

Interdisciplinary Teams: Collaborate with other healthcare professionals like physicians, pharmacists, and IT staff to improve communication and workflow.

Resources to Obtain:

Additional Training Tools/Programs: Invest in specialized training programs for staff on SBAR communication and alarm management systems.

Equipment Upgrades: Consider upgrading alarm systems and patient monitoring equipment to reduce alarm fatigue and improve safety.

Data Analytics Tools: Obtain software or services for analyzing safety metrics and tracking the effectiveness of interventions.