Writink Services

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

  • NURS FPX 4020 Assessment 2

Like healthcare competition, safeguarding patients is a crucial concept. Lack of staffing in the ER is a significant concern due to its effects on patients, the occupational health of health facility workers, and the overall system. This root cause analysis and safety improvement plan focuses on explaining and placing recommendations for addressing the issue related to staffing shortages. The selected patient safety problem originates from medication-related mistakes, high mortality, and high meritoriousness associated with the low staffing ratio of nurses in erythrocytes.

Driven by the purpose of examining the anti-immigrant sentiment pervading the US and the reasons behind it, this paper aims to identify all the factors associated with the problem and discuss the most effective and feasible solution. To achieve those goals and futures, this venture focuses on identifying the cause and possible solutions to improve patient’s safety and the quality of their care in facilities.

Analysis of the Root Cause

Issue Description in ER

The patient safety issue here is staff deficit within healthcare institutions. The specific event that led to this concern was the reported medication errors and overall enhanced mortality rates among patients with an increased nurse-to-patient ratio (Lasater et al., 2021).

The problem was detected through a comprehensive review of patient outcomes and satisfaction metrics, which revealed a correlation between understaffed conditions and adverse events. The issue affected both healthcare professionals and patients. Insufficient staffing led to a heightened workload for individual healthcare providers, increasing stress, burnout, and fatigue (Kovacs & Lagarde, 2022). This, in turn, contributed to oversights, missed care, and delayed responses to patient needs. Patients perceived rushed or unavailable staff, impacting their satisfaction and reducing trust in the healthcare system (Karaca & Durna, 2019). The cumulative effect compromised the overall quality of care provided.

Analysis of the Event and Relevant Findings

The analysis revealed several contributing factors, such as workload and communication. Notably, the intended steps in patient care were hindered due to the increased workload, leading to deviations from standard protocols. Environmental factors such as the constant pressure and long hours in understaffed conditions contributed to human errors and burnout among healthcare professionals (Dall’Ora et al., 2020).

In other factors, there were communication issues, which worsened the effect of a shortage of personnel in healthcare facilities. Towards this, the root cause that can be derived with certainty is that the staffing levels of establishments are impacted by resource scarcity, policies regarding human capital management, and an overall lack of strategic workforce development. The issues include not hiring and organizing human resources and not providing servants for insufficient and changeable patient traffic (Senek et al., 2022). Environmental and communication factors are highlighted as sustaining the issue and, therefore, can negatively influence the overall effectiveness of patient care.

Application of Evidence-Based Strategies in the ER Department

Best practice approaches from the literature show the need for evidence-based practices to address the safety concerns of staffing shortages in healthcare organizations. The literature indicates that interruptions while administering medications lead to medication administration errors, underlining why any workload challenges must be addressed (Lasater et al., 2021). One evidence-based strategy to address this problem is integrating technology whereby Electronic Health Records are used to improve the Systems and reduce medication errors, as highlighted by Hamad and Bah (2022). EHRs provide effective solutions for documenting and disseminating vital information in the patient’s records for healthcare practitioners.

Another example of best practices is the Automated Medication Dispensing Systems that Positive Healthcare implemented. These systems increase the efficiency of giving drugs and decrease the amount of work done by the nurses, in addition to improving the aspect of safe medication administrations (Alanazi et al., 2022).

Implementing the staffing models regarding assignment, demand, effectiveness, and optimization involves several metrics and critical factors that may require workforce analytics and predictive tools for improvement (Griffiths et al., 2021). Data analytics can predict patient flow early, meaning the staffing levels in healthcare facilities can be well adjusted in advance, avoiding the common scenarios where there are too many staff and cases with very few staff. Another advantage that comes with nurse staffing pools or the use of float staff is that organizations are better placed to respond to the variability observed in patient traffic and conditions.

Investing in staff training and development programs is a crucial strategy to enhance workforce resilience and proficiency. Continuous education on patient safety protocols, evidence-based practices, and stress management empowers healthcare professionals to navigate challenges effectively, ensuring high-quality care under demanding circumstances (Søvold et al., 2021). These evidence-based strategies collectively address the root cause of staffing shortages by enhancing communication, leveraging technology, optimizing staffing models, and promoting workforce resilience.

Improvement Plan with Evidence-Based and Best-Practice Strategies in the ER Department

There is a need to implement the best approaches or methods supported by research to avoid the safety problem of staff shortages in healthcare. HAAD 303 Vanderbilt Task 1 The literature shows that interruptions during medication administration pose a risk and, hence, another workload challenge area (Lasater et al., 2021). For example, integrating EHRs and other technology-based interventions has been deemed effective in cutting across communication barriers and enhancing the flow of communication while avoiding medication mistakes (Hamad & Bah, 2022).

This is an advantageous way of data sharing with other parties in the health care delivery team since EHR has mechanisms of record keeping that are both accurate and timely.

Another best practice is Automated medication dispensing systems. These systems improve the medication administration process, including efficiency and accuracy, relieve the nursing workload, and decrease potential adverse medication errors (Alanazi et al., 2022). By integrating such systems, healthcare facilities can enhance medication management practices, minimize errors, and optimize resource utilization.

NURS FPX 4020 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

As the technology becomes more innovative, efforts will tackle staff training and development to balance the enhancement of workforce capability and stamina. EBPs emphasize how education enhances patient safety and protocols emphasizing stress management (Søvold et al., 2021). In the following paragraphs, relevant academic literature will be described to support the argument for the implementation of professional development plans in healthcare organizations: By implementing professional development initiatives, current healthcare employees shall be equipped with the necessary knowledge and skills that shall enable them to work effectively within the challenging healthcare facilities.

Some interventions that form part of the implementation plan include mapping out the care processes and modifying them to enhance the flow of care and utilize protocols and tools in safe medication management. These factors are crucial for professional development interventions to assist in providing more reliable and satisfactory outcomes of care service. This includes implementing proper and consistent normative guidelines and processes, decreasing potential mistakes, and promoting patient safety and efficient care. In summary, the action plan for technology adoption caters to staff training and development and standardizing patient processes to achieve better patient safety and quality care.


The time frame for the development and realization of the plan will be done in stages, where the technology-supported solutions will be offered during the first half of the implementation period. This will require both the purchase of EHRs and integration with automated medication dispensing systems. At the same time, one of the most critical milestones will be continued staff training for implementing evidence-based practice and reducing stress levels at work.

It is expected that during the next six months, there will be further consolidation of care process standardization across all aspects of patient care. There will be feedback mechanisms of the process that will enable the constant evaluation of the improvement processes in the area of patient safety, the results of which will form the basis of the subsequent continuous development and change according to the modern tendencies in the healthcare sphere. The critical components of the safety improvement plan shall be anchored on the references from peer-reviewed articles and the best practices for every aspect.

Existing Organizational Resources in the ER department

The following table lists several existing organizational resources that may be utilized to strengthen the identified deficiency of the safety improvement plan, which can be attributed to staffing shortages. First, the task area where the Information Technology (IT) department plays a critical role is highly likely to implement technology solutions. Engaging other IT specialists to participate in EHRs and automated medication dispensing systems’ buying, implementing, and fine-tuning is possible and can be speedy.

They have unique skills that help transition from old technologies to new ones without disrupting everyday functionality. Staff training and development requires the support and involvement of many individuals, especially the Human Resources or personnel officers. They have the necessary expertise in managing educational programs, keeping attendance records, and evaluating the success rate of training sessions. HR can also use this policy to set up communication between healthcare professionals and the training officers. It is beneficial to involve HR as early as possible to ensure that the whole process of the implementation of ideas in the field of workforce development will take as little time as possible.

ER nurse managers and other leaders are crucial in effectively implementing the plan. Some essential aspects are engaging the leader’s participation and support to instill a safety culture, encouraging compliance with evidence-based practice, and encouraging effective communication among the healthcare team staff. Communication and engagement with the nursing leadership shall ensure that the improvement plan aligns with the overall organizational direction and goal-setting toward patient safety (Haskins & Roets, 2022).

More resources are available, and future investments could be made to achieve the best results. For example, one may be able to provide funds for training enhancement modules, acquisition of sophisticated technologies, or possibly changing staff rotations to add a practical training timetable.


Addressing staffing shortages in healthcare demands a comprehensive and evidence-based approach. The proposed safety improvement plan incorporates technology-enabled solutions, staff training programs, and standardized care processes supported by scholarly literature and professional best practices.

Leveraging existing organizational resources, particularly from IT, HR, and nursing leadership, enhances the plan’s potential impact. The phased implementation and continuous monitoring ensure adaptability to the evolving healthcare landscape. Through this concerted effort, healthcare organizations can mitigate the risks associated with staffing shortages, fostering a safety culture and providing high-quality patient care. The commitment to evidence-based strategies and collaboration across various stakeholders underscores the dedication to building a resilient and sustainable healthcare system.
Click below to explore more related samples:
nurs fpx 4020 assessment 1 enhancing quality and safety


Alanazi, M. F., Shahein, M. I., Alsharif, H. M., Alotaibi, S. M., Alanazi, A. O., Alanazi, A. O., Alharbe, U. A., Almfalh, H. S. S., Amirthalingam, P., Hamdan, A. M., Veeramani, V. P., Mohamed, S. H. P., & Sayed Ali, M. A. (2022). Impact of automated drug dispensing system on patient safety. Pharmacy Practice, 20(4), 01–11.


American Nurses Association. (2022). Nurse staffing advocacy. ANA.


Carthon, J. M. B., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of Nursing Care Quality, 34(1), 40–46.


Dall’Ora, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: A theoretical review. Human Resources for Health, 18(1), 1–17.


De Hert, S. (2020). Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local and Regional Anesthesia, 13(13), 171–183.


Flaubert, J. L., Menestrel, S. L., Williams, D. R., & Wakefield, M. K. (2021). Supporting the health and professional well-being of nurses. www.ncbi.nlm.nih.gov. National Academies Press.


Griffiths, P., Saville, C., Ball, J. E., Jones, J., & Monks, T. (2021). Beyond ratios – flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: A simulation and economic modeling study. International Journal of Nursing Studies, 117(117).


Hamad, M. M. E., & Bah, S. (2022). Impact of implementing electronic health records on medication safety at a HIMSS stage 6 hospital: The pharmacist’s perspective. Canadian Journal of Hospital Pharmacy, 75(4), 267–275.


Haskins, H. E. M., & Roets, L. (2022). Nurse leadership: Sustaining a culture of safety. Health SA Gesondheid, 27(0), 8.


Karaca, A., & Durna, Z. (2019). Patient satisfaction with the quality of nursing care. Nursing Open, 6(2), 535–545.


Kovacs, R., & Lagarde, M. (2022). Does high workload reduce the quality of healthcare? Evidence from rural Senegal. Journal of Health Economics, 82(1).


Lasater, K. B., Aiken, L. H., Sloane, D., French, R., Martin, B., Alexander, M., & McHugh, M. D. (2021). Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: An observational study. BMJ Open, 11(12).


Senek, M., Robertson, S., Taylor, B., Wood, E., King, R., & Ryan, T. (2022). Consequences of understaffing on type of missed community care- a cross-sectional study. International Journal of Nursing Studies Advances, 4(1).


Søvold, L. E., Naslund, J. A., Kousoulis, A. A., Saxena, S., Qoronfleh, M. W., Grobler, C., & Münter, L. (2021). Prioritizing healthcare workers’ mental health and well-being: An urgent global public health priority. Frontiers in Public Health, 9(1), 1–12.


Leave a Reply

Please Fill The Following to Resume Reading

    Please Enter Active Contact Information For OTP

    Verification is necessary to avoid bots.