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

Student name

Capella University

FPX4035

Professor Name

Submission Date

Scenario

Mr. J. is a 62-year-old male who was admitted to the Intensive Care Unit (ICU) during a busy night shift with complaints of shortness of breath, chest pain, and fatigue. The attending physician initially suspected pneumonia and ordered antibiotics along with a chest X-ray for further evaluation.

During monitoring, the nurse identified abnormal electrocardiogram (ECG) changes along with elevated troponin levels, both of which are indicative of potential acute myocardial infarction (AMI). However, due to high patient workload, staffing pressures, and delayed handoff communication, these critical findings were not communicated to the physician in a timely manner.

Within 12 hours of admission, the patient experienced cardiac arrest. A subsequent review confirmed that the patient had been suffering from an acute myocardial infarction that was not initially recognized. This diagnostic delay resulted in significant harm, including prolonged ICU stay, increased healthcare costs, and severe emotional distress for both the patient and his family.

This sentinel event highlights a breakdown in clinical communication, failure of timely escalation, and missed recognition of critical diagnostic data, all of which contributed to a preventable adverse outcome.

Understanding What Happened
What happened? Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context.	The sentinel occasion affected the affected person the maximum of all as he experienced the maximum excessive cardiac complications, cardiac arrest, and a extended length of stay at the ICU owing to the incapability to diagnose the initial caution signs of myocardial infarction and provide the affected person with the quintessential treatment, and pneumonia. This had contributed to delayed affliction, better treatment expenses, and not on time recuperation. The spouse and children of the struggling patient have been emotionally startled and had no greater confidence in the health care device, however the ICU clinical personnel had to encounter moral traumas, pressure, and worry of being sued on account of the error. The medical facility also suffered by virtue of its recognition, expanded economic burden, and the possibility of malpractice fits (corridor et al., 2020).
Who did the problem/event affect, and how?	But the ICU scientific personnel had to come across moral traumas, pressure, and worry of being sued because of the error. The scientific facility additionally suffered due to its popularity, multiplied monetary burden, and the opportunity of malpractice fits (hall et al., 2020).
Why did it happen?:Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.System Factors: Examine workflow processes, equipment failures, and environmental factors.Organizational Culture: Assess if there are cultural issues, a lack of safety culture, or inadequate leadership support. Society/Culture: What role might cultural assumptions or backgrounds play?	The motives behind the sentinel occasion were human elements, system problems, organizational way of life, and societal pressures. The cognitive factors (anchoring and untimely closure) predisposed the doctor to make a untimely prognosis of pneumonia and no longer take into account the causes of cardiac starting place. The lab reviews were inconsistent, and the nurse used to be so overworked and exhausted that she did no longer expand strange results so quickly. system-related issues (disjointed electronic health facts, delays in lab and ECG results, absence of computerized imperative values notification) and inconsistent documentation in case of a change of shifts led to the emergence of statistics gaps that postponed the shipping of lab and ECG findings (earlier et al., 2023). The ICU had quite a venture-oriented tradition, wherein speedy interventions were on the whole targeting the most glaringly quintessential cases and did not awareness a whole lot on the diagnostic overview, second critiques, and effective management of the diagnostic safety (Dietl et al., 2023). in addition, on account of a excessive affected person remember and the societal expectancies to offer speedy diagnoses, clinicians had been overwhelmed with the responsibility of having to make short selections and no longer always awareness on alternative causes (Balogh et al., 2019).
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.	Sure. according to the policies of the Joint fee and company of Healthcare research and fine (AHRQ), one ought to acquire the effects of diagnostic exams as rapid as feasible and respond to unusual check values right away. however, the closed-loop communication of the troponin consequences was no longer present, and turning in shifts with standardized SBAR reporting was once not applied. The high-quality practices were now not located in view that reviewing checklists used to be no longer accomplished (Khafaji et al., 2022). Early caution signs records have been additionally incomplete, and this also behind schedule the commentary of the cardiac occasion.
Who was involved?:Staff: Identify the roles of individuals directly involved in the event. Supervisors and Managers: Investigate	Workforce: Direct engagement used to be with an attending health practitioner who did the preliminary analysis and an ICU nurse who used to be tracking the patient. Supervisors and executives: The nurses and ICU supervisors have been also no longer present seeing that they didn’t body of workers and survey the quality of the handovers appropriately. Ancillary workforce: ECG and laboratory technicians generated the records however did not have an street for relaying any essential values to clinicians. management: The nice and safety officials failed to bring within the diagnostic choice assist and compliance with communication standards.
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. The interdisciplinary conversation between shifts was once missing – the atypical information on the lab, and the ECG were no longer discussed. Its conversation used to be not in a loop since the nurse believed that the health practitioner might have found out the results, while the physician assumed that every one things within the lab were ok. This aligns with the consequences of evaluation 1 that proved that verbal exchange and failure to take the take a look at are very common a number of the motives that can bring about misdiagnosis (Dietl et al., 2023). The degree of conversation between the affected person and the issuer was additionally now not so high; the own family and the patient were no longer privy to the exams to be conducted, so they could not make the argument of their favour.
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.	Bodily surroundings: The busy ICU graph distracted the attention of the team of workers, distracting them, growing noise, and a loss of a handy working environment to check take a look at consequences and compose a greater precise diagnostic argument. Staffing degrees: The pandemic understaffing helped to create an overload and exhaustion some of the personnel and limited the time needed to carry out diagnostic overview and cooperation (prior et al., 2023). schooling and Competency: Khafaji et al. (2022) located that employees lacked refresher education at the signs of early MI and systematic diagnosis idea

Did organizational policies or procedures play a role?:Policy Compliance: Investigate if policies were followed.Policy Clarity: Assess if policies are clear and accessible.	Yes. There was no policy in the organization that required the closed-loop communication feature of abnormal test results, and organized SBAR handovers were not witnessed. The policies of diagnostic safety were paper-based, but no implementation and monitoring of the same took place. This gap also corresponds to the information that diagnostic error is also a contributor that is related to lax policy enforcement (Hall et al., 2020).
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. The deviant vitals and lab findings of the patient were not adhered to and monitored in real time. The realization of the worsening trends was impeded by alert fatigue and high workloads, which aligns with the findings that ineffective surveillance systems are connected with delayed diagnosis (Vally et al., 2023).
What can be learned to prevent recurrence?Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.Quality Improvement: Consider implementing preventive measures.	A number of the instructions, the subsequent ones are a few of the most critical: established diagnostic checklists, choice-assist device, closed-loop conversation protocols, and automated notifications of vital values need to be added. Multidisciplinary diagnostic huddles have to be instituted in an try to take a look at complicated instances. staff contributors might be knowledgeable in cognitive debiasing and early symptom recognition, a great thanks to beautify a extra correct diagnosis. The improvement of a life-style of remarks and mastering approximately diagnostic near-misses may even reduce the dangers (Kobrai-Abkenar et al., 2024).
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.	The required measures to enhance affected person safety may be applied in the danger mitigation, training, and remarks structures domain names. The installation of automated alert structures (in case of strange effects), dependent SBAR, handover, and the implementation of diagnostic safety checklists into every day exercising may want to reduce the chance. The schooling and training need to be completed with a purpose to get the clinicians more aware of the cognitive biases, greater appropriate functionality to recognize the signs of early myocardial infarction, and their potential if you want to motive in a scientific shape of analysis. furthermore, the diagnostic errors reporting structures and feedback loop can be followed to offer clinicians with the opportunity to study the ignored prognosis and continually enhance the diagnostic accuracy (business enterprise for Healthcare studies and terrific, 2025).

Root reason(s) to the difficulty or sentinel event?

After of completion of the evaluation above, kindly imply clearly one or greater root reasons that led to the difficulty or sentinel event. Kindly observe the factors noted above and tick all the root reasons which can be relevant.

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

Absence of communication of abnormal results of troponin/ECG is due to the absence of closed-loop communication.

HF-C

The doctor was burdened with a diagnosis of pneumonia and could not re-examine it when there was some opposing information.

HF-T

The nurse did not create warning signs due to work overload and exhaustion.

HF-F/S

None to provide an automated alert or a built-in system to indicate critical results.

Lack of standardized SBAR handover and policy implementation that is not understood.

The culture had low status on diagnostic review or second opinions.

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 practice to address diagnostic errors and cognitive bias includes handover strategies that are designed to include Situation-Background-Assessment-Recommendation (SBAR), closed-loop communication to convey critical written outcomes, and multidisciplinary diagnostic huddles (Khafaji et al., 2022). EHR abnormal lab alerts are automatic to promote timely identification (Prior et al., 2023). Feedback systems can provide clinicians with a chance to learn the lesson of using mistakes in diagnostic performance (Balogh et al., 2020). These would be directly applied to human, system, and communication failures that lead to this sentinel event.

Explain how the strategies could be applied to the safety issues or sentinel events you have identified.

The proposed evidence-based recommendations are integrable in order to prevent such an incident as the occurrence of a diagnostic error, as the sentinel event in question. Closed-loop communication and the application of structured SBAR handovers will ensure the identification of all abnormal test outcomes (i. e., troponin elevations or ECG changes), their discussion, and documentation before the shift change and prevent the information loss. The cardiac causes will be memorized in the decision-support tools and diagnostic checklists included in the EHR, and can motivate clinicians to consider cardiac causes when patients have overlapping symptoms, such as chest discomfort and fatigue, and help in removing cognitive biases, such as anchoring. To prevent an untimely detection of abnormal results, EHR notifications will facilitate the timely detection of dangerous laboratory or ECG values by an automated system to provide the care team with an opportunity to intervene in time. The teams will be empowered to review near-misses and patterns and the idea of error education in order to improve clinical reasoning at the group level through multidisciplinary diagnostic review huddles and feedback systems. Lastly, the power of clinicians to recognize the high-risk cases early enough and avoid premature closure will be enhanced with the help of the refresher training on the measures of cognitive bias mitigation and early MI symptoms. The application of these strategies will address the communication, system, and human factors that caused the missed myocardial infarction in the case under study and ultimately improve the diagnostic safety and outcome of the patients.

Action Plan One for each Root Cause/Contributing Factor from above	E / C / A Choose one
Closed-loop communication and SBAR-based structured handovers will be implemented to avoid the loss of results.	C
Offer early warning signs of MI, reduction of cognitive bias, and diagnostic reasoning refresher training.	C
Install automated EHR notifications on important lab/ECG findings.	E
Hold routinely scheduled diagnostic huddles and peer feedback to discuss missed cases.	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 enterprise will intention at introducing several specialised tactics and development programs to relieve the underlying reasons of the diagnostic errors. categorical rules can be ready to subject closed-loop verbal exchange to all of the various meaningful effects of the prognosis to make certain the bizarre findings are recognized, escalated, and recorded inside due time. All clinical units will be delivered to formal SBAR handover exercises to transfer the affected person information in a uniform way and save you omissions within the shift-to-shift transfers. in addition, the quarterly diagnostic protection training and simulation activities may be introduced to enhance the team of workers’s competence in the abilities of detecting the first signs and symptoms of myocardial infarction, applying systematized diagnostic reasoning, and reducing the have an impact on of cognitive biases. moreover, a formal reporting and feedback gadget of the diagnostic errors will be set up, according with which the body of workers participants will file near-misses and get positive feedback that will help them growth their diagnostic selection-making capabilities even further.

Describe the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.

The overall aim of these interventions is to lessen the mistakes in diagnoses and decorate interdisciplinary communication, and decorate patient safety consequences. it will likely be implemented in tiers as a way to be powerful and lasting. Months one and 2 will be spent at the development of succinct regulations, the creation of dependent SBAR handovers, and the installation of EHR-structured signals regarding vital diagnostic values. The 0.33 and fourth months could be allotted to the personnel education at the identity of myocardial infarction, the lower of cognitive bias, and systematic diagnostic thinking. the new reporting and comments structures and multidisciplinary diagnostic huddles could be added inside the fifth to sixth month to enhance real-time collaboration and getting to know. these interventions could be maintained for the reason that seventh month onwards, with the perpetuation of such interventions via persevered tracking and regular remarks meetings, and cultural applications, in an effort to guarantee the long-time period dedication to diagnostic safety throughout the complete organisation.

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.

EHR infrastructure can help alert structures with a new one. best and safety departments can brainstorm approximately coverage and display their compliance. Harding clinicians are capable of rent peer mentorship at some stage in the diagnostic huddles. the instructional departments can carry out simulations and common schooling. it’ll help in safe and sustainable implementation when the assets are used.

References

Agency for Healthcare Research and Quality. (2025). Join the Ideas Project to advance diagnostic safety. https://www.ahrq.gov/news/newsletters/e-newsletter/966.html

Balogh, E. P., Miller, B. T., & Ball, J. R. (2020). The diagnostic process. National Academies Press. 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. https://doi.org/10.3389/fpsyg.2023.1164288

Hall, K. K., Shoemaker-Hunt, S., Hoffman, L., Richard, S., Gall, E., Schoyer, E., Costar, D., Gale, B., Schiff, G., Miller, K., Earl, T., Katapodis, N., Sheedy, C., Wyant, B., Bacon, O., Hassol, A., Schneiderman, S., Woo, M., LeRoy, L., & Fitall, E. (2020). Diagnostic errors. In Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555525/

Khafaji, A. J., Townsend, R. F., Townsend, W., Chopra, V., & Gupta, A. (2022). Checklists to reduce diagnostic error: A systematic review of the literature using a human factors framework. BMJ 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

Prior, A., Vestergaard, C. H., Vedsted, P., Smith, S. M., Virgilsen, L. F., Rasmussen, L. A., & Fenger-Grøn, M. (2023). Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: A Danish nationwide cohort study. BMC Medicine, 21(1). https://doi.org/10.1186/s12916-023-03021-3

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