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
Professor Name
Submission Date
Root-Cause Analysis and Safety Improvement Plan
-
Scenario
Mr J. is a 62-year-old male who has been taken to the Intensive Care Unit (ICU) in the middle of a hectic night shift and he reports of shortness of breath, chest pain and fatigue. The attending physician had a pneumonia suspicion and prescribed antibiotics and a chest X-ray was awaited. The nurse who was working with the patient has noticed slight changes in the Electrocardiogram (ECG) and an elevation of the troponin level, which were not provided to the doctor on time due to the high number of patients and the delay in the handover.
The patient subsequently went into cardiac arrest 12 hours later, and at that point, it was discovered that he had an acute myocardial infarction that was not initially noticed when he was initially examined. The result of such a false diagnosis was an acute delay in treatment and a long stay of the patient in the ICU and a high level of emotional stress in the patient and his family.
| Understanding What Happened | |
| What happened?: The first step is to know the flow of events before the sentinel event. Get a lot of information regarding the incident, the time of the incident, the people involved and the situation.
What person/people were impacted by the problem/event? |
The patient was the most critical victim of the sentinel event because he suffered the greatest cardiac complications, cardiac arrest, and a long stay in the ICU because of the failure to recognize the initial red flags of myocardial infarction and provide the patient with the appropriate treatment, and pneumonia.
This had brought about misery tardy with increased expenses and retarded healing of therapy. The patient affected, the family suffered various emotional shocks and loss of trust into the healthcare system; medical staff of the ICU had moral traumas and stress and feared being sued because of the misfortune. Its reputation and additional financial burden, not to mention the possible malpractice suits, also damaged the healthcare organization (Hall et al., 2020). |
| Why did it happen?:
Human Factors: Research the possibility of communication failures, fatigue of staff, or insufficient training. System Factors: Investigate the working processes, equipment malfunctioning and the environment. Organizational Culture: Determine whether their culture has problems, safety culture deficit, or insufficient leadership. o Society/Culture: What do cultural assumptions or backgrounds do we have? |
Human factors, system issues, organizational culture, and social pressures were the causes of the sentinel event. The cognitive factors (anchoring and premature closure) also affected the physician to make an early diagnosis of pneumonia and ignore the cardiac causes, and the inconsistent lab reports, and the workload and fatigue of the nurse delayed the development of abnormal outcomes.
Information was not coordinated due to issues with the system, such as decoupled electronic health records, which delayed the delivery of laboratory and ECG results, inefficient automated critical values messaging, and inconsistent documentation in case of change of shifts (Prior et al., 2023). The culture in the ICU was rather task-oriented based on the need to intervene the most openly critical cases as soon as possible and not very focused on the diagnostic review, second opinions, and good leadership control over the diagnostic safety (Dietl et al., 2023). Moreover, the large amount of patients and societal pressures to provide fast diagnoses left clinicians with the necessity to make fast decisions and not to thoroughly consider the available alternative causes (Balogh et al., 2019). |
| Were the procedures or standards violated:
Procedures and Policies: Find out whether the laid down procedures were observed or there were deviations. Did anything go wrong or fail to go as was planned? Documentation: Examine medical records, nursing notes and other documentation. |
Yes. The suggestions provided by the Joint Commission and the Agency of Healthcare Research and Quality (AHRQ) mean that the diagnostic tests results are supposed to be obtained in the shortest possible time and that the response to the abnormal test results must be prompt.
The provision of shifts was not linked to standardized SBAR reporting but the closed-loop communication of the troponin results was absent. The best practices were not achieved, as they did not imply checklists review (Khafaji et al., 2022). Early warning signs records were not complete as well and this further delayed the detection of the cardiac events. |
| Who was involved?:
Staff: Find out the position of those who are directly involved in the event. Supervisors and Managers: Research. |
Staff: The direct involvement was of an attending physician who diagnosed the patient first and ICU nurse who was on the patient.
Supervisors and Managers: The ICU and nurses supervisors were also absent since they did not staff and survey the quality of the handovers adequately. Ancillary Staff: Technicians were laboratory and ECG and lacked a system to transfer vital values to clinicians. Leadership: The quality and compliance officers did not instill diagnostic decision support and adherence to the norms of communication. |
| Did there occur a failure of communication?:
Interdisciplinary Communication: Determine the effectiveness of various teams in communication. Patient-Provider Communication: Investigate the awareness and understanding of patients in regards to their care. |
Yes. There was no interdisciplinary communication between the shifts – there was no discussion of abnormal data offered by the lab and ECG. Closure loop communication was not created because the nurse thought that the doctor would have been informed about the outcome but the doctor was thinking that all was well in the lab.
This is in accordance with the findings of Assessment 1 that disclosed that diagnostic errors are usually caused by communication and missing test scores ( Dietl et al., 2023). The patient-provider communication was also not high; the family and the patient were not informed about the tests to be done, therefore, they could not defend themselves. |
| What were some of the factors:
Physical Environment: Reflect on facility layout, availability of equipment and work spaces. Staffing Levels: Assess whether there was sufficient staffing. Training and Competency: Evaluate employees in terms of knowledge and skills. |
Physical Environment: The ICU was extremely crowded and the hectic environment distracted the staff who did not have a quiet space to read through the test results and make a personalized, full-fledged diagnosis argument.
Staffing Levels: The chronic understaffing predetermined the overload and exhaustion of the staff, and reduced the time to conduct a diagnostic check and cooperate (Prior et al., 2023). Training and Competency: Khafaji et al. (2022) discovered that the employees did not have systematic diagnostic thoughts and refresher training on the symptoms of early-onset MI. |
| Was there a contribution of organizational policies or procedures:
Policy Compliance: Investigate whether policies were adhered to. Policy Clarity: Evaluate whether or not policies are transparent and available. |
Yes. The closed-loop communication aspect of the abnormal test results within the organization did not have a policy, and no structured handovers of SBAR in the form were observed. The diagnostics safety policies were in paper form but there was no implementation and monitoring of the same. Such a gap is also in line with the discovery that the absence of policy implementation is among the reasons that resulted in diagnostic errors (Hall et al., 2020). |
| Was there any lapse in surveillance or monitoring:
Vital Signs Monitoring: Determine whether any signs were missed. Alarm Fatigue: Investigate whether alarms had been neglected. |
Yes. There was no close adherence to and real-time monitoring of the deviant vitals and lab results of the patient. The aggravating tendencies were manifested at a slower rate by red fatigue and work overload, which is consistent with the results that poor surveillance systems are related to a late diagnosis (Vally et al., 2023). |
| Lesson to be learned to avoid repetition:
Lessons Learned: Determine systemic change, training requirements and areas of improvement. Quality Improvement: Prevention measures should be taken into account. |
One of the most important lessons, one should mention that structured diagnostic checklists, decision-support tool, closed-loop communication protocols, and automated notifications of critical values should be presented. The multidisciplinary diagnostic huddles must be established in order to refer to complex cases.
The staff members will be taught cognitive debiasing and early symptom identification which will improve the precision of diagnosis. The risks will be also minimized by building a culture of feedback and learning about diagnostic near-misses (Kobrai-Abkenar et al., 2024). |
| In what ways can patient safety be improved?:
Risk Mitigation: Strategy-formulate ways of reducing risks. Education and Training: Be sure of well trained staff. Reporting and Feedback: Promote open reporting and mistakes. |
The identified areas that can be enhanced by the targeted strategies to promote patient safety include risk mitigation, education and feedback systems. The installation of automated alert systems to abnormal results, structured SBAR, handover and the introduction of diagnostic safety checklists into the everyday practice would reduce the risk.
There is the need to conduct training and education programs to enhance the level of awareness of the clinicians on the cognitive biases, improved capacity to recognize the symptoms of early myocardial infarction and enhanced capacity to reason in systematic diagnosis format. Moreover, the system of reporting diagnostic errors and feedback can be introduced to help clinicians learn of the missed diagnosis and continuously improve the diagnostic accuracy (Agency for Healthcare Research and Quality, 2025). |
Root Cause(s) to the issue or sentinel event?
Upon completion of the analysis above, please explicitly state one or more root causes that led to the issue or sentinel event. Please refer to the factors discussed above and categorise each root cause by choosing all that apply.
| Root Cause – the most basic reason that the situation occurred | Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal | HFC | HF T | HF
F/S |
E | R | B | |
| 1 | Absence of communication of abnormal troponin/ECG due to absence of closed loop communication. | HF-C | ||||||
| 2 | The doctor got pneumonia as a diagnosis and did not reconsider once there was contradictory information. | HF-T | ||||||
| 3 | The nurse did not create warning signals due to work overload and fatigue. | HF-F/S | ||||||
| 4 | None of the automated warning or built-in mechanisms to indicate critical results. | E | ||||||
| 5 | Lack of standardized SBAR handover and inappropriate policy implementation. | R | ||||||
| 6 | The culture had low regard to diagnostic review or second opinions. | B |
HF-C = Human Factor-communication HF-T = Human Factor-training HF-F/S = Human Factor-fatigue/scheduling
E= environment/equipment R= rules/policies/procedures B=barriers
Application of Evidence-Based Strategies
Identify evidence-based best practice strategies to address the safety issue or sentinel event.
| The evidence-based interventions to address diagnostic errors and cognitive bias include handover strategies in the form of Situation-Background-Assessment-Recommendation (SBAR), closed-loop communication to convey critical outcomes, and multidisciplinary diagnostic huddles (Khafaji et al., 2022). EHR abnormal lab alerts are automated to improve the timely detection (Prior et al., 2023). Feedback systems on diagnostic performance can enable clinicians to learn by making errors (Balogh et al., 2020). These would be directly implemented to human, system and communication failures that were the sources of this sentinel event. |
Explain how the strategies could be applied to the safety issues or sentinel events you have identified.
| The proposed evidence-based actions can be directly put in place to prevent such an occurrence as a diagnostic error, like the one described as a sentinel event. Closed-loop communication and the application of ordered SBAR handovers will ensure that all the abnormal test results (i.e., troponin elevations or ECG changes) are identified, discussed, and documented prior to the shift change and avoid the information wastage. The cardiac causes will be memorized in the decision-support tools and diagnostic checklists inbuilt into the EHR and can motivate clinicians to consider cardiac causes when patients have overlapping symptoms, such as chest discomfort and fatigue and aid in the eradication of cognitive biases, such as anchoring.
The EHR notifications will make sure that abnormal results will be identified early by automated alerts of critical laboratory or ECG values so that the care team can intervene before it is too late. To improve clinical reasoning on a group level, multidisciplinary diagnostic review huddles and feedback systems will enable teams to reexamine near-misses and patterns, and error education. Lastly, the refresher training on the actions of cognitive bias reduction and early MI symptoms will increase the strength of clinicians who will identify the high-risk cases early and avoid premature closure. These strategies will address the communication, system, and human factors that contributed to the missed myocardial infarction in the case under analysis and will ultimately improve the diagnostic safety and the outcome of the patients. |
Safety Improvement Plan
List any future actions needed to prevent recurrence.
| Action Plan
One for each Root Cause/Contributing Factor from above |
E / C / A
Choose one |
|
| 1 | To prevent the loss of results, closed-loop communication and SBAR-based structured handovers will be adopted. | C |
| 2 | Provide early MI symptoms, cognitive bias and diagnostic reasoning refresher education. | C |
| 3 | Conduct periodic diagnostic and/or peer feedback huddles regularly to address missed cases. | E |
| 4 | Install automated EHR alarms on critical lab/ECG results. | A |
E = eliminate (i.e., a piece of equipment is removed, fixed or replaced.)
C = control (i.e. additional step/warning is added or staff is educated/re-educated)
A = accept (i.e. formal or informal discussions of “don’t let it happen again” or “pay better attention” but nothing else will change, and the risk is accepted)
Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).
| The organization will implement various specialist procedures and developmental programs to reduce the causes of the diagnostic errors. The categorical policies will be ready to enforce closed-loop communication to all the notable diagnostic results in order to ensure that the abnormal results are identified, escalated and recorded promptly. To ensure that patient information transfer and omission in the shift-to-shift transfers are eliminated, formal SBAR handover routines will be applied to all clinical units.
Besides, quarterly diagnostic safety education and simulation-based training will be introduced to enhance the competence of the staff in the skills to recognize the first signs of myocardial infarction, apply methodical diagnostic reasoning, and reduce the contribution of cognitive biases. In addition, a formal reporting and feedback mechanism of diagnostic error will be adopted to promote the non-punitive learning culture whereby the staff members will report near-misses and receive feedback so that they can further enhance their diagnostic decision-making abilities.
|
Describe the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.
| The general goal of these interventions is to reduce the number of diagnostic errors and enhance interdisciplinary communication, and enhance patient safety outcomes. Its introduction will be in phases which will be effective and sustainable. Month one and two will be focused on developing short policies, introducing structured handovers of SBAR, and organizing EHR-based alerts of critical diagnostic values.
The third and fourth months will be spent on offering training to the personnel on the identification of myocardial infarction, the minimization of cognitive bias, and the systematic thought of diagnosis. In months five to six, the implementation of multidisciplinary diagnostic huddles and the new reporting and feedback systems will be done to improve the real-time collaboration and learning. These interventions will be facilitated since the seventh month onwards through remaining to monitor, periodic feedback meetings, and cultural programs, which will guarantee a long-term commitment to diagnostic safety in the entire organization. |
Existing Organizational Resources
Identify resources that may need to be obtained for the success of the safety improvement plan. Consider what existing resources may be leveraged to enhance the improvement plan.
| The alert systems can be supported by new EHR infrastructure. The quality and safety departments can formulate policies and monitor their implementation. There is potential use of peer mentorship by Harding clinicians in diagnostic huddles. The educational departments could do simulations and regular training. Upon the use of the resources it will assist in safe and sustainable implementation. |
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References for NURS FPX 4035 Assessment 2
Agency for healthcare research quality. (2025). Join the Ideas Project To Advance Diagnostic Safety. Ahrq.gov. https://www.ahrq.gov/news/newsletters/e-newsletter/966.html
Balogh, E. P., Miller, B. T., & Ball, J. R. (2020). The diagnostic process. Nih.gov; National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK338593/
Dietl, J. E., Derksen, C., Keller, F. M., & Lippke, S. (2023). Interdisciplinary and interprofessional communication intervention: How psychological safety fosters communication and increases patient safety. Frontiers in Psychology, 14(14). https://doi.org/10.3389/fpsyg.2023.1164288
Diagnostic Errors. In www.ncbi.nlm.nih.gov. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555525/
British Medical Journals Open, 12(4). https://doi.org/10.1136/bmjopen-2021-058219
Kobrai-Abkenar, F., Salimi, S., & Pourghane, P. (2024). “Interprofessional collaboration” among pharmacists, physicians, and nurses: A hybrid concept analysis. Iranian Journal of Nursing and Midwifery Research, 29(2), 238. https://doi.org/10.4103/ijnmr.ijnmr_336_22
Vally, Z. I., Khammissa, R. A. G., Feller, G., Ballyram, R., Beetge, M.-M., & Khammissa, R. A. G. (2023). Errors in clinical diagnosis: A narrative review. Journal of International Medical Research, 51(8). https://doi.org/10.1177/03000605231162798
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