Root-Cause Analysis and Safety Improvement Plan

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 man who reported to the Intensive Care Unit (ICU) in the middle of the busy night shift and complained about shortness of breath, chest pain, and fatigue. The attending physician suspected the patient of having pneumonia and placed an order for antibiotics, and a chest X-ray was in progress. The Electrocardiogram (ECG) showed minor changes and a rise in the level of troponin, which the nurse attending the patient detected, but this was not communicated to the doctor promptly due to the high number of patients and delayed handover. In 12 hours, the patient went into cardiac arrest, and it was then discovered that he had an acute myocardial infarction, which was overlooked when he was initially examined. Such a false diagnosis caused a critical delay in treatment, a prolonged stay at the ICU, and extreme emotional distress among the patient and his family. Understanding What Happened   1. 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. o Who did the problem/event affect, and how? The sentinel event affected the patient the most of all as he experienced the most severe cardiac complications, cardiac arrest, and a prolonged period of stay at the ICU due to the inability to diagnose the initial warning signs of myocardial infarction and provide the patient with the necessary treatment, and pneumonia. This had contributed to delayed agony, higher treatment costs, and delayed recovery. The relatives of the suffering patient were emotionally shocked and had no more confidence in the health care system, but the ICU medical personnel had to encounter moral traumas, stress, and fear of being sued because of the error. The medical facility also suffered because of its reputation, increased financial burden, and the possibility of malpractice suits (Hall et al., 2020). 2. Why did it happen?: o Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed. o System Factors: Examine workflow processes, equipment failures, and environmental factors. o Organizational Culture: Assess if there are cultural issues, a lack of safety culture, or inadequate leadership support. o Society/Culture: What role might cultural assumptions or backgrounds play? The reasons behind the sentinel event were human factors, system issues, organizational culture, and societal pressures. The cognitive factors (anchoring and premature closure) predisposed the physician to make a premature diagnosis of pneumonia and not take into account the causes of cardiac origin. The lab reports were inconsistent, and the nurse was so overworked and exhausted that she did not develop abnormal results so soon. System-related problems (disjointed electronic health records, delays in lab and ECG results, absence of automated critical values notification) and inconsistent documentation in case of a change of shifts led to the emergence of information gaps that postponed the delivery of lab and ECG findings (Prior et al., 2023). The ICU had quite a task-oriented culture, where rapid interventions were primarily concentrated on the most obviously critical cases and did not focus much on the diagnostic review, second opinions, and effective leadership of the diagnostic safety (Dietl et al., 2023). Further, due to a high patient count and the societal expectations to offer rapid diagnoses, clinicians were overwhelmed with the responsibility of having to make quick decisions and not necessarily focus on alternative causes (Balogh et al., 2019). 3. Was there a deviation from protocols or standards?: o Procedures and Policies: Determine if established protocols were followed or if there were deviations. o Were there any steps that were not taken or did not happen as intended? o Documentation: Review medical records, nursing notes, and other relevant documentation. Yes. According to the rules of the Joint Commission and Agency of Healthcare Research and Quality (AHRQ), one should receive the results of diagnostic tests as fast as possible and respond to atypical test values promptly. However, the closed-loop communication of the troponin results was not present, and delivering shifts with standardized SBAR reporting was not utilized. The best practices were not observed since reviewing checklists was not done (Khafaji et al., 2022). Early warning signs records were also incomplete, and this also delayed the observation of the cardiac event. 4. Who was involved?: o Staff: Identify the roles of individuals directly involved in the event. o Supervisors and Managers: Investigate Staff: Direct engagement was with an attending physician who did the initial diagnosis and an ICU nurse who was monitoring the patient. Supervisors and Managers: The nurses and ICU supervisors were also not present since they failed to staff and survey the quality of the handovers appropriately. Ancillary Staff: ECG and laboratory technicians generated the data but did not have an avenue for relaying any vital values to clinicians. Leadership: The quality and safety officers failed to bring in the diagnostic decision support and compliance with communication criteria. 5. Was there a breakdown in communication?: o Interdisciplinary Communication: Assess how well different teams communicated. o Patient-Provider Communication: Explore whether patients were informed and understood their care. Yes. The interdisciplinary communication between shifts was lacking – the abnormal information at the lab, and the ECG were not discussed. Its communication was not in a loop since the nurse believed that the doctor would have realized the outcomes, whereas the doctor assumed that all things in the lab were okay. This aligns with the results of Assessment 1 that proved that communication and failure to take the test are very common among the reasons that may result in misdiagnosis (Dietl et al., 2023). The degree of communication between the patient and the provider was also not so high; the family and the patient were not aware of the tests to be conducted, so they could not make the argument in their favour. 6. What were the contributing factors?: o Physical Environment: Consider facility layout, equipment availability, and workspaces. o Staffing Levels: Evaluate if staffing was adequate. 7. Training and Competency: Assess staff’s knowledge and skills. Physical Environment: The busy ICU layout distracted the attention of the staff, distracting them, creating noise,