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Root-Cause Analysis and Safety Improvement Plan

Maureen

Root-Cause Analysis and Safety Improvement Plan

Several risks are associated with patient safety in healthcare systems, especially when there is a delay in identifying aspects of the patient’s condition. This paper aims to provide a root-cause analysis (RCA) of such delays and recommend a plan for improving safety to tackle this problem. This case review, analysis, and application of an evidence-based approach to addressing identified causal factors are meant to improve patient safety and quality of care.

Root-Cause Analysis of the Patient Safety Issue

The event under analysis concerns a sentinel event in which a patient with a respiratory infection had severe respiratory difficulties, and the staff acted inappropriately. This delay resulted in the patient being taken to the ICU in a very critical condition. This situation was discovered by a bedside nurse who realized that the patient was experiencing difficulty breathing and his oxygen levels were declining. When presenting these discoveries to the attending physician, the response was lethargic, which led to the worsening of the patient’s health, as well as overworking the healthcare team and causing them elevated stress levels. This patient’s hypoxia duration required ALS and led to his prolonged hospitalization and multiple treatments. This also led to questions being raised by the patient’s family regarding the quality of care that they were receiving.

Several reasons led to a delay in response. Ideally, ongoing evaluation and intervention should have occurred if there was any sign of patient deterioration. However, several critical steps were either not taken or came pretty late. The main issues were that the nurse could not constantly monitor the patient due to the number of patients she was attending to, the delayed response of the physician, and the lack of initial basic interventions such as giving the patient oxygen. This was because aspects such as increased patient turnover in the emergency department and high patient density also contributed to the delay. After all, the nurse was not always able to continually assess the patient’s status. Another factor highlighted by Inglis et al. (2019) that led to the delay includes limitations in equipment and resources, such as a lack of advanced equipment to support respiratory needs. Other aspects that contributed to the high rate of medical errors were the overload and fatigue of the healthcare staff. Due to the congestion of patients, the nurse might have overlooked the condition of the patient, hence delaying to report to the physician. Another problem that affected the functioning of the team was the lack of communication. The nurse may have disclosed the wrong information concerning the emergency, or the physician may not have grasped the gravity of the situation due to insufficient data.

Root causes should be distinguished so that proper solutions can be implemented. These include lack of staff, poor communication structure, lack of training on signs of a deteriorating patient, and inefficient processes. Eradicating these causes entails adopting interventions and practices informed by research evidence.

Application of Evidence-Based Strategies

Enhancing communication is a good strategy. Examples of standardized writing tools include SBAR (Situation, Background, Assessment, Recommendation), which makes communication more explicit and time-sensitive (Murphy et al., 2022). Martínez-Fernández et al. (2022) revealed that SBAR enhances communication effectiveness and the time elapsed in the event of emergent circumstances. It is also important to perform adequate staffing levels. Increasing the number of nurses also reduces the response time and improves the patient’s condition. This means that staffing policies of the healthcare facility need to be analyzed and changed to address the needs of the patients appropriately. Comprehensive educational interventions are needed to enhance the ability of healthcare personnel to identify the sick or those at risk of deteriorating quickly. Regular training and simulation enable the enhancement of the thought process and swift response, which are essential during emergencies. Simulation-based training is particularly useful in improving staff preparedness and proficiency.

Evaluating and redesigning processes to eliminate time wastage and achieve better organizational flow is also pursued. This entails reducing paperwork and ensuring that medical equipment is easily accessible and that working environments are arranged to allow for quick responses to decisions. The applications of EHRs, telehealth, and Clinical Decision Support Systems also help in the early identification of patients who require interventions, thus enabling caregivers to attend to the needs of the deteriorating patients (Tsai et al., 2020).

Improvement Plan with Evidence-Based and Best-Practice Strategies

The following improvement plan is suggested to address the mentioned root causes to effectively deal with the problems and enhance patient safety. Some of the measures included in this plan are the use of SBAR communication forms, increasing staffing, offering training sessions, improving processes, and applying technology.

Implementing SBAR Communication Protocols

Enhancing Staffing Levels

Comprehensive Training Programs

Workflow Optimization

Existing Organizational Resources

Utilization of organizational resources is important in the implementation of the improvement plan. The adoption of protocols and technology has benefited from the participation of experienced nurses, physicians, and other healthcare professionals in the role of trainers and mentors (Ardestani et al., 2023). Like most facilities, the healthcare organization has already implemented EHRs and other technologies that would support the goals of the improvement plan in terms of communication, workflow, and patient monitoring. This indicates that current training departments can expand and implement effective training initiatives for all employees to identify patients on the trajectory towards deterioration. In addition, many healthcare organizations have committees or task forces for quality improvement and patient safety. These groups can help implement the improvement plan in that they can supervise the progress of the plan and the changes that are required. Although it may cost some money, the healthcare facility can seek grants and funding from government health and non-governmental organizations on patient safety and quality of care.

Conclusion

Failure to identify and address changes in a patient’s status in a timely manner presents a major threat to patient outcomes. Such a scenario contributes to delays that require a root-cause analysis to determine why they occur and how they may be prevented. By employing best practices, including protocolized communication, sufficient staffing, training, proper scheduling, and technology, it is possible to minimize delays and enhance the results of their patients. Hence, it is relevant to utilize the resources that are already available within the organization and obtain the required funding for the safety improvement plan. Thus, healthcare organizations can develop measures to prevent adverse events and continuously improve the quality of care for patients. Since all possible causes of delays are dealt with in a structured manner, this approach benefits overall patient care and patient safety.

References

Ardestani, S. F. M., Adibi, S., Golshan, A., & Sadeghian, P. (2023). Factors influencing the effectiveness of E-learning in healthcare: A fuzzy ANP study. Healthcare, 11(14), 2035. https://doi.org/10.3390/healthcare11142035

Inglis, R., Ayebale, E., & Schultz, M. J. (2019). Optimizing respiratory management in resource-limited settings. Current Opinion in Critical Care, 25(1), 45–53. https://doi.org/10.1097/mcc.0000000000000568

Martínez-Fernández, M. C., Castiñeiras-Martín, S., Liébana-Presa, C., Fernández-Martínez, E., Gomes, L., & Marques-Sanchez, P. (2022). SBAR method for improving well-being in the internal medicine unit: Quasi-experimental research. International Journal of Environmental Research and Public Health, 19(24), 16813. https://doi.org/10.3390/ijerph192416813

Murphy, M., Engel, J. R., McGugan, L., McKenzie, R., Thompson, J. A., & Turner, K. M. (2022). Implementing a Standardized Communication Tool in an Intensive Care Unit. Critical Care Nurse, 42(3), 56–64. https://doi.org/10.4037/ccn2022154

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 1–27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761950/

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Question 

For this assessment, you can use a supplied template to conduct a root-cause analysis.

Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

The completed assessment will be a scholarly paper focusing on a quality or safety issue in a health care setting of your choice as well as a safety improvement plan.

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