Root-Cause Analysis and Safety Improvement Plan – Staffing Shortages in Healthcare

Root-Cause Analysis and Safety Improvement Plan – Staffing Shortages in Healthcare

Staffing shortages in healthcare pose persistent and serious problems that threaten both patient safety and performance as well as nurse well-being. The problem is especially apparent in hospitals, where intense patient demands and insufficient numbers of nurses lead to delays in care, drug administration mistakes, and high levels of nurse fatigue. Healthcare facilities across the country are feeling increased strain due to the shortage of qualified nurses caused by aging workers, nurse burnout arising from the pandemic, and poor staffing practices. This paper explores how a root-cause analysis (RCA) can identify the underlying factors and causes of the staffing problem and the systemic breakdowns it leads to. It will examine why staffing issues have arisen and draw effective strategies from proven approaches to improve safety. A system will be created to implement the plans effectively with the necessary resources. The objective is to prevent serious medical errors and ensure high-quality care by finding long-term solutions to the staffing predicament.

Analysis of the Root Cause

This root-cause analysis focuses on a sentinel event in which an elderly patient developed a stage II pressure injury due to prolonged immobility during an understaffed weekend shift in a medical-surgical unit. The nurse in charge of the unit was able to identify the issue when several reports and patient complaints showed that certain needed care was not administered. The event caused issues for patients and the medical staff. Patients noticed that the standard of care declined, and nurses were placed at greater risk of causing harm while dealing with excessive workloads and feeling stressed.

Ideally, each nurse should have managed no more than four to five patients, ensuring regular monitoring, repositioning, and proactive care. Instead, due to staffing shortages, nurses were assigned to 10 or more patients, causing critical lapses in care. Key steps in the care process were missed, including patient rounding and high-risk skin assessments. Environmental factors included a holiday surge in admissions and poor staffing contingency planning. Controllable factors, such as the absence of a float pool or standby staff, compounded delays. Equipment shortages, particularly insufficient availability of functioning beds and assistive devices, added to care inefficiencies. Fatigue-related human errors and poor shift handoffs also contributed to oversight of patient needs. The root causes include chronic workforce shortages, lack of real-time acuity-based staffing, and the absence of proactive scheduling tools. Without structural and policy-level interventions, similar sentinel events are likely to recur, compromising both patient outcomes and staff retention.

Poor communication played a major role in the occurrence of a stage II pressure injury. Unfinished reports and failure to conduct interdisciplinary rounds allowed oversights in identifying individuals with an increased danger of developing pressure injuries. Slow information transfer into the EHR bottlenecked the speedy initiation of protective measures. Lack of efficient information exchange and common protocols for shared decision-makingMake criteria confound educational assistance early in capacity. According to McKnight and Moore (2022), shared governance improves communication channels and helps colleagues speak up about safety issues. The lack of well-defined communication channels and collaborative methods made it difficult to ensure effective coordination of care, which raised the chance of negative results and revealed fundamental issues in team-based clinical communication.

Application of Evidence-Based Strategies

Staffing shortages in healthcare are consistently linked to negative patient outcomes, increased nurse burnout, and adverse sentinel events. The literature identifies several best-practice strategies to mitigate these risks. One of the most well-supported interventions is the implementation of mandated nurse-to-patient ratios. McHugh et al. (2021) found that hospitals with a 4:1 patient-to-nurse ratio reported significantly lower mortality, fewer readmissions, and reduced length of stay compared to those with higher ratios. This suggests that overburdening nurses with excessive workloads directly contributes to preventable complications such as missed assessments, medication errors, and poor patient monitoring.

Studies have found that predictive scheduling can result in better scheduling outcomes. Twigg et al. (2021) argue that suitable AI and acuity-based tools forecast the amount of required staff with reference to both patient characteristics and patient volume. This approach makes it less likely for there to be delays and strengthens continuity in care, mainly during periods with high admissions, such as holidays.

Wellness initiatives and flexible work policies have also been shown to enhance nurse retention and decrease burnout, both key contributors to chronic shortages. According to Falatah (2021), stress and severe workloads were the leading causes of nurses choosing to leave their jobs during and after the pandemic. Offering support for mental health, allowing flexible schedules, and offering education and training courses keep people interested and less likely to leave the company. Staffing ratios, predictive scheduling, and wellness programs address the main reasons for clinical sentinel events and improve safety in healthcare.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Addressing the root problems affecting staff numbers and safety for patients starts with a solid and workable safety plan. It is made up of three related strategies. Implementing equal nurse-to-patient ratios, having forecasting tools for scheduling, and introducing wellness plans for all staff. With these strategies in place, the goal is to promote safer care, lessen issues and raise nurses’ commitment to the medical-surgical team.

The first step is introducing a mandate that requires setting nurse-patient ratios. The plan suggests a nurse-to-patient ratio of 4:1 in general medical-surgical units and 2:1 in intensive care units. McHugh et al. (2021) concluded that adopting such ratios would reduce mortality rates, quicken patient recovery, and make nurses less likely to experience burnout. Setting these ratios helps alleviate nurse workloads and allows them to provide quality nursing care.

The plan will also implement a predictive, acuity-based scheduling system. It’s powered by AI and keeps staffing decisions up-to-date based on the ever-changing patient counts and their medical needs. Twigg et al. (2021) found that such systems improve the way workloads are shared, trouble-free scheduling, and how efficiently staff members operate. Sessions will be organized for nurse managers and scheduling coordinators to teach them how to properly work with the software.

The third component focuses on staff well-being. A structured wellness program will offer flexible scheduling options, access to counseling services, resilience workshops, and recognition initiatives. As Falatah (2021) notes, these interventions are effective in reducing emotional exhaustion and turnover, particularly in the aftermath of the COVID-19 pandemic.

The plan’s implementation will span six months. The first two months will focus on policy finalization, staff training, and system integration. Months three and four will involve full rollout, followed by evaluation and adjustments based on feedback in months five and six. The expected outcomes include reduced turnover, improved satisfaction, and fewer care-related adverse events.

Existing Organizational Resources

The successful implementation of the proposed safety improvement plan relies heavily on leveraging existing organizational personnel and infrastructure. CNOs and unit nurse managers are responsible for making sure the number of nurses per patient is followed and that predictive scheduling software is effectively used. The HR team will lend a hand in recruiting new staff, retaining current workers, and implementing programs that support employees’ health. Also, the Quality and Safety group will be essential for checking metrics such as staff turnover, patient/employee feedback, and key events throughout this implementation.

The IT department, which looks after managing electronic health records (EHRs), will also aid in integrating AI-based schedulers. Educational departments may present workshops on up-to-date tools and available wellness activities. Nevertheless, further resources are necessary, for example, licensing costs for predictive software, support for resilience training by outside facilitators, and help with staffing in times of transition. Exploiting both internal and external resources increases the feasibility and maintains the sustainability of the plan.

Conclusion

Staffing shortages in healthcare pose significant threats to patient safety, nurse well-being, and organizational performance. The analysis found that these shortages were mainly caused by weak staffing systems, staff burnout, and not using technology enough. The improvement plan proposes adopting safe nurse-to-patient ratios, using prediction scheduling, and setting up programs to encourage the well-being of staff. Under nursing leadership, human resources, and IT assistance, the plan can be carried out successfully. Securing good staffing and assisting nurses through teamwork allows healthcare organizations to avoid sentinel events and improve the safety and outcomes for patients. Regularly monitoring outcomes and adjustments helps to maintain the advantages gained from the project and keep it flexible.

References

Falatah, R. (2021). The impact of the coronavirus disease (COVID-19) pandemic on nurses’ turnover intention: An integrative review. Nursing Reports, 11(4), 787–810. https://doi.org/10.3390/nursrep11040075

McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905–1913. https://doi.org/10.1016/s0140-6736(21)00768-6

McKnight, H., & Moore, S. M. (2022, September 19). Nursing shared governance. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK549862/

Twigg, D. E., Whitehead, L., Doleman, G., & El‐Zaemey, S. (2021). The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing, 77(12), 4599–4611. https://doi.org/10.1111/jan.14909

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Root-Cause Analysis and Safety Improvement Plan – Staffing Shortages in Healthcare

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the safety quality issue presented in your Assessment Supplement PDF in Assessment 1. Based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting, provide a rationale for your plan.

Root-Cause Analysis and Safety Improvement Plan

Use the Root-Cause Analysis and Improvement Plan [DOCX] Download Root-Cause Analysis and Improvement Plan [DOCX]template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

Analyze the root cause of a specific patient safety issue in an organization.
Apply evidence-based and best-practice strategies to address the safety issue.
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Identify organizational resources that could be leveraged to improve your plan.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to a specific patient safety issue.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on the quality issue you selected in Assessment 1.(Assessment 1
Enhancing Quality and Safety)