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.
   • Who did the problem/event affect, and how?

She was not provided with visual aids or post-discharge follow-up. This incident resulted in preventable physical distress, emotional anxiety, and hospital costs. It also highlighted systemic failures in communication and discharge planning. Both the patient and healthcare team were negatively affected, emphasizing the need for improved patient education protocols.

1. 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, lack of safety culture, or inadequate leadership support.
   • Society/Culture: What role might cultural assumptions or backgrounds play?

Systemically, there was no standardized discharge education protocol, and the workflow lacked checkpoints to verify patient understanding. The organizational culture treated education as a secondary task, with no oversight or structured process. Additionally, cultural and literacy barriers were overlooked.

The patient’s low health literacy and independent living status were not considered in tailoring education or arranging support, reflecting implicit cultural assumptions and inadequate social risk assessment. These factors together created conditions for preventable harm.

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.

There was no use of health literacy tools, nor was the patient’s ability to follow instructions evaluated. Steps such as involving an interpreter or caregiver, assessing readiness for discharge, or providing follow-up instructions in simple language were not taken. Documentation in the electronic health record (EHR) only reflected that discharge instructions were “provided,” without details on the method used or patient response.

This lack of thorough documentation suggests minimal compliance with education standards and a missed opportunity for quality assurance (Gonçalves-Bradley et al., 2022). The error played a direct role in the readmission of the patient.

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

The pharmacy technician did not document any medication counseling. Supervisors, including the charge nurse and unit manager, were aware of the discharge process but failed to provide oversight due to staffing constraints. This lack of coordinated accountability contributed to the breakdown in patient education.

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.

The nurse and physician did not communicate about the patient’s health literacy needs. On the patient-provider level, the patient was given written instructions without verbal reinforcement or a chance to ask questions. She did not understand her care plan but felt uncomfortable expressing confusion, highlighting a failure to create an open, supportive environment for effective communication (Zota et al., 2023).

1. What were the contributing factors?:
   • Physical Environment: Consider facility layout, equipment availability, and workspaces.
   • Staffing Levels: Evaluate if staffing was adequate.
2. Training and Competency: Assess staff’s knowledge and skills.

Staffing levels were inadequate, with nurses stretched thin across multiple patients, limiting time for one-on-one teaching. This high workload environment led to task prioritization, where patient education was rushed or bypassed altogether, undermining comprehension and retention of critical discharge information (Gonçalves-Bradley et al., 2022).

The staff involved in the discharge process had not received formal training in health literacy communication strategies or the application of the teach-back method. This gap in competency contributed to the failure to assess patient understanding effectively. Without foundational knowledge in culturally responsive care and patient education techniques, nurses may unintentionally overlook the unique needs of individuals with low literacy levels, leading to miscommunication and adverse outcomes (Talevski et al., 2020; Zota et al., 2023).

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.

As a result, compliance was inconsistent and largely dependent on individual staff judgment. The policy itself was not prominently accessible nor reinforced through training or routine audits. This lack of clarity and accountability created gaps in practice, allowing critical patient safety steps to be missed without consequences, ultimately leading to the preventable readmission (Gonçalves-Bradley et al., 2022; Talevski et al., 2020).

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.

This oversight reflects a missed opportunity for early intervention. The lack of structured post-discharge surveillance for high-risk patients like those with CHF significantly increases the likelihood of readmission and compromises patient safety (Gonçalves-Bradley et al., 2022; Villani & Trivedi, 2020).

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

Training needs can be seen, especially in terms of effective communication, cultural competency, and the use of educational tools intended for use in patients with limited literacy. Medical institutions should create an environment in which patient knowledge is as important as treatment.

Preventative strategies like placing prompts in EHR that confirm that the information was understood, assigning a liaison for discharge, or scheduling follow-up phone calls for high-risk patients within 48 hours can significantly slow down the number of preventable readmissions.

It is also recommended to provide feedback on quality improvement initiatives and to ensure compliance with these initiatives by implementing a regular audit (Talevski et al., 2020; Zota et al., 2023). Finally, a proactive, systematized method may help improve safety, minimize harm, and empower patients in self-care.

1. How can patient safety be enhanced?:
   • Risk Mitigation: Develop strategies to minimize risks.
   • Education and Training: Ensure staff are well-trained.
2. Reporting and Feedback: Encourage open reporting and learning from mistakes.

Risk can also be minimized by singling out high-risk individuals like chronic patients or those with cognitive limitations, or language problems, and focusing on them, having longer education and monitoring. By using multilingual educational resources and sharing them with the EHR, it is possible to distribute the delivery identically to all staff. Implementing routine follow-up calls after discharge within 48 hours will enable faster detection of possible confusion, medicine errors, or a relapse of symptoms (Gonçalves-Bradley et al., 2022).

In addition to improved patient safety, these interventions will lead to an improvement in patient outcomes by decreasing the preventable readmission rate and facilitating continuity of care following hospitalization.

The durable literacy of reporting and feedback is critical to ongoing enhancement of patient safety. System-level learning has possibilities when frontline staff can report education-related omissions, like missed steps or ambiguous instructions. Open approaches and accountability can be achieved through non-punitive feedback processes that enable staff to determine and address education barriers (Zota et al., 2023).

There should also be follow-up surveys or calls to collect feedback in order to detect gaps in communication. These insights allow quality improvement teams to make improvements to discharge protocols, training, and corrective measures, which will help eliminate the recurrence of similar issues and make patient care deliveries much safer and responsive.

F/S

2.       Nurse did not assess patient comprehension (no teach-back)

3.       Low patient health literacy overlooked

Another best practice is utilizing multimedia education tools, such as videos, infographics, to help reach low-literacy populations, who might need language adaptation (Pierce et al., 2025). Also, Gonçalves-Bradley et al. (2022) mention that the use of post-discharge follow-up calls decreases 30-day readmissions. The research also recommends health literacy assessment and application of culturally appropriate communication methods as critical elements of holistic patient education (Zota et al., 2023). Taken together, these strategies will allow shaping a basis to enhance the process of communication and guarantee that a patient is prepared to safely control their situation following discharge.

Multimedia education packets can be auto-generated based on diagnosis, and interpreters should be available for real-time clarification. Implementing a 48-hour post-discharge call system for high-risk patients allows case managers to assess adherence, answer questions, and intervene if issues arise (Gonçalves-Bradley et al., 2022).

These strategies will promote consistent, personalized education and create accountability among staff, reducing the chance of repeated communication failures. When supported by leadership and technology, this multi-pronged approach fosters a safer discharge process and better long-term health outcomes.

One for each Root Cause/Contributing Factor from above

Choose one

This training will include simulations and competency assessments conducted by nurse educators. To resolve the third issue, patient education materials will be redesigned to meet a 5th–6th-grade reading level and offered in multiple languages. Multimedia resources, such as short instructional videos and visual guides, will also be developed and linked within the patient portal. High-risk patients will be flagged for post-discharge phone calls within 48 hours, conducted by case managers or discharge nurses to reinforce teaching and identify any barriers to compliance.

Post-discharge call procedures will be implemented in month five, with patient education materials and multilingual resources fully available by month six. Ongoing audits and compliance reviews will be conducted monthly by the quality improvement team to ensure effectiveness and identify opportunities for adjustment.

The patient portal can be used to distribute multimedia education tools and instructional videos post-discharge. The case management team, already involved in care coordination, can conduct follow-up phone calls to reinforce patient understanding and detect early issues. Additionally, the quality improvement department can track readmission rates, audit compliance, and provide feedback.

To fully implement the plan, minor investments may be needed in video production, health literacy materials, and additional discharge training modules. These resources will help integrate and sustain the improvement strategies effectively.