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

Understanding What Happened

The patient was a 45-year-old nurse in the emergency department, Emily. Emily was experiencing verbal aggression several times during the night shift with a group of high acuity patients when she was working at an understaffed emergency department, and a family member came to visit the patient. The aggressiveness caused Emily to feel nervous and distracted, which resulted in administering a medication necessary late, which worsened the situation of the patient and provided him with an extension of the hospital stay.

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 emergency department nurse, Emily, was the most affected and had to bear both verbal aggression of a spoken and threatened nature, which left her nervous and distracted. This not only canceled out her safety and well-being but also increased her risk of being stressed, burned out, and having low morale. This indirectly impacted the patient because he was held up until he could receive important medication, further worsening the situation and increasing hospitalization. Such events also endanger the healthcare organization as the underreporting of violence and medical errors causes the escalation of the costs due to the extended length of stay, absenteeism, and potential employee turnover (Kafle et al., 2022).

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 violent situation in the case of Emily was fulfilled in the interplay of human, system, organizational, and cultural factors. Human factors predetermined the inability to address the aggression effectively as they included the exhaustion of the staff members who had to work with numerous patients with high acuity, as well as the absence of de-escalation training (Goodman et al., 2020). The understaffing of the emergency department, the fact that the area had to wait a lot, and the fact that the reporting system is not standardized were also enablers of the issue and allowed the incident to go unreported (Veronesi et al., 2023).

The organization level had a low safety culture and involvement of the leaders, which created gaps in the policies that left the nurses with no sufficient assistance or confidence to report the aggression (Arnetz, 2022). The broader social and cultural factors also added to it because the violence of the family member was preconditioned by the stigma of mental illness, drug use, and unrealistic expectations of fast help in the emergency setting (Recsky et al., 2023). All of these factors that are interdependent made it possible to perpetuate the issue of workplace violence that placed Emily and her patients in harm’s way.

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.

In the example of Emily, it was clear that there was negligence in the normal procedures and safety measures. Although the national organizations, such as The Joint Commission and the American Nurses Association, promote the concept of zero-tolerance and the introduction of systematic reporting of workplace violence, they have not put these concepts into practice (Arnetz, 2022). The most significant actions, including reporting and recording the aggression of the family member as soon as possible, were not undertaken, and this is why the administrators failed to find the patterns and implement preventative measures.

Additionally, there was no organized de-escalation training, which meant that Emily, along with her colleagues, was not prepared to follow the evidence-based principles in the situations where the aggressive behaviour became more and more active. Such laxities of compliance and undocumented records showed that the incident was not attended to adequately, and both Emily and her patients were exposed to further risks of harm.

4. Who was involved?:

o Staff: Identify the roles of individuals directly involved in the event.

o Supervisors and Managers: Investigate

The incident entailed the parties on a number of levels of personnel and management in the case of Emily. The direct impact was on the frontline nurses, as Emily was not only verbally threatened and intimidated but also had to take care of patients, which contributed even more to the risk of making an error and creating delays. The physicians were also involved indirectly since they sanctioned continuity of care during the disruptive encounter.

The managers and supervisors, who included the nurse leaders and hospital administrators, were the ones who supported the safety assurance, but they could not maintain the safety standards through their failure to implement the zero-tolerance policy, inadequate staffing, and lack of resources in the form of de-escalation training and effective security mechanisms. Security personnel were included as well in the list of the key stakeholders, and during the incident, they were absent, and Emily had to deal with the aggression alone without any direct support. The lack of unified help and leadership control together allowed getting out of control and putting the health of both the nurse and the patients at risk (Arnetz, 2022).

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.

The interdisciplinary communication in the incident was not successful because the communication between the nursing staff and security personnel was not effective. Security did not provide Emily with the timely support. Moreover, the lack of a central reporting mechanism meant that the incidence was never reported to the administration, which ruled out leaders being able to pick trends and implement preventive measures. This corresponds to workplace violence, where no one reports, which impedes the inter-clinical, security, and administrator coordination (Veronesi et al., 2023).

These communication lapses lead to more risks to the staff and the patients (Tikva et al., 2024). The alerts and structured reporting should be offered fast to prevent escalation and patient safety. Communication between the patient and the provider was also disrupted as the aggressive family member and high-acuity workload distracted Emily and made her anxious, probably did not allow her to provide the patient with timely explanations, which would minimize his understanding and trust. Poor communication and lack of empathy are caused by stressful conditions and disorientation of the staff, which, in turn, can influence patient safety and satisfaction (Tikva et al., 2024). Communication with patients should be structured even in high-stress levels to ensure the safety and efficacy of care.

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.

There were several causes of the incident. The absence of security coverage, combined with the physical layout of the bustling and high-acuity emergency department, provided stressful conditions to complicate the management of aggressive behavior (Recsky et al., 2023). There was also understaffing, where Emily was left alone with some of the high-acuity patients, putting an extra burden on the staff. It aligns with the fact that a large nurse-to-patient ratio reduces de-escalation and timely interventions (Goodman et al., 2020). Finally, the nurse lacked definite training in de-escalation or crisis intervention, and insufficient conflict management training is also known to impede staff competencies in the area of safely coping with aggression.

8. Did organizational policies or procedures play a role?:

o Policy Compliance: Investigate if policies were followed.

o Policy Clarity: Assess if policies are clear and accessible.

Policies and procedures in the organization played a role in the incident. The fact that the standardized reporting system was not used meant that Emily had not formally reported the incident of aggression. This means that compliance with the policy was not complete, and this leadership was unaware of the potential risks involved (Veronesi et al., 2023). In addition, the circumstance suggests the existence of policy ambiguity and unavailability since the employees were not clearly told how to access emergency security support when faced with violent behavior. There can be no coordination and timely interventions, risk reduction to staff and patients without clear or well-utilised policies (Tikva et al., 2024).

9. Was there a failure in monitoring or surveillance?:

o Vital Signs Monitoring: Check if there were any missed signs.

o Alarm Fatigue: Explore if alarms were ignored.

Yes, there was failure in monitoring and surveillance. It was also evidenced by the fact that Emily was not concerned with the task of dealing with the aggressive family member, but merely with the administration of a critical medication. It shows that the patient did not obtain vital signs monitoring and patient needs monitoring as fast as they had to, which, in turn, worsened the patient’s condition (Tikva et al., 2024). The situation does not presuppose the alarm specifically, though the characteristics of the high-acuity environment and excessive workload of the staff members include a risk of alarm fatigue or slow responses, which may lead to inadequate staffing and environmental conditions that may weaken timely monitoring and care provision to patients (Goodman et al., 2020; Recsky et al., 2023).

10. What can be learned to prevent recurrence?

o Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.

o Quality Improvement: Consider implementing preventive measures.

Several lessons can be obtained so that such incidents could be mitigated. Systemic changes entail a standardized reporting system, transparent and easy-to-understand policies that employees can use to request urgent security help, which would improve interdisciplinary communication and timely interventions (Veronesi et al., 2023). The training requirements are linked to the process of providing the nurses with training on de-escalation and crisis intervention, and also providing them with better skills to manage aggressive patients and visitors (Price et al., 2024).

Among the areas to be improved, it might be staffing high-acuity units to reduce stress and distraction, physical environment, such as safety equipment, such as panic buttons and controlled access, and an incident-reporting and learning culture. The combination of staff education, changing the environment, and the introduction of the policy can reduce violence at the workplace, enhance patient safety, and make staff more prepared to act more efficiently in the situation in the future (Volonnino et al., 2024).

11. How can patient safety be enhanced?:

o Risk Mitigation: Develop strategies to minimize risks.

o Education and Training: Ensure staff are well-trained.

12. Reporting and Feedback: Encourage open reporting and learning from mistakes.

Patient safety can be increased using strategies of different types. The increase in the level of interdisciplinary communication, adequate staffing, and physical environment adjustments, such as panic buttons and limited access to the high-risk areas, is referred to as risk reduction (Volonnino et al., 2024). It needs education and training, such as teaching nurses techniques of de-escalation, conflict resolution, and crisis intervention strategies to be in a position to respond to violent patients or visitors (Price et al., 2024). Furthermore, the culture of reporting and feedback should be introduced to document and analyze the incidents to apply them as an instructional tool for future consistent improvement, ensuring that the staff and leadership would learn from their mistakes and prevent them (Veronesi et al., 2023; Tikva et al., 2024). A combination of these measures will result in increased patient safety, reduction of errors, and a safer healthcare environment.

Root Cause– themost 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

E

R

B

1

The inability to form interdisciplinary communication between the nursing and the security staff, along with the fact that there was no formal reporting, stated that timely intervention and awareness in the leadership were not established, and that is one of the reasons that caused the delayed medication administration.

HF-C

2

The patient has not been specifically trained on de-escalation and crisis management, meaning that Emily was not able to deal with the violent family member safely, but was able to get stressed and distracted in the process of care delivery.

HF-F

3

The emergency department was high acuity, and it was understaffed, thus making the workloads and stress even more demanding, lowering Emily’s capacity to check patients and respond to the emergency needs.

HF

F/S

4

The Actual circumstances of the overcrowded emergency department, the absence of security guards, and panic keys or locked doors were unsafe conditions, which created the freedom to allow the situation to escalate.

E

5

Lack of a standard reporting mechanism and instructions that could not be read on how to seek immediate security help were some of the reasons behind the insufficient adherence to the policy and action.

R

6

It was not a good case scenario since increased acuity of the patients, violent relatives of the patients, and unarranged support systems aggravated the problem.

B

The evidence-based solutions to the problem of workplace violence and patient safety improvement rest on a number of causal factors of the situation. The structured reporting systems will ensure that the incidences are recorded, patterns are identified, and preventive measures are taken (Veronesi et al., 2023). The de-escalation and crisis management training would equip the nurses with the information needed to safely manage aggressive patients or visitors to remove stress and avoid any mistakes (Price et al., 2024). Other parameters to avoid fatigue and intervene in time are staffing in high-acuity units (Recsky et al., 2023). Such environmental safety precautions as controlled access, the presence of security, and panic can help to reduce the potential risk of violent encounters (Volonnino et al., 2024). Safety and quality can also be improved by the availability of transparent policies and having a supportive culture that encourages reporting, peer support, and continuous feedback (Tikva et al., 2024). The strategies are combined to provide solutions to the system, human, and environmental factors that facilitate the risk of workplace violence and patient safety.

The use of evidence-based practices might be applied directly to prevent the repetition of a similar incident to that of Emily. Use of a standardized reporting system would imply that the aggressive encounters are an official record, and administrators can utilize the security resources more effectively as they will be aware of the trends (Veronesi et al., 2023; Arnetz, 2022). By learning to de-escalate or manage a crisis, the nurses would learn how to handle a hostile patient or family member safely, and the result of such an intervention would be a reduction of stress, distraction, and delayed care (Price et al., 2024). Proper staffing of the acuity zones would alleviate the workload and fatigue so that the nurses could check the vital signs and take the necessary interventions at the right time. Environmental safety would increase the speed of reaction to the aggressive behaviours; it would help to have controlled access to sensitive areas, panic buttons, and increase security presence (Volonnino et al., 2024). Finally, the establishment of explicit policies and the advancement of a reporting, feedback, and peer-supporting culture would guide the behaviours of the staff in the event of incidents and ensure uninterrupted learning, which would eventually lead to better patient safety and eliminate harm to the staff (Tikva et al., 2024).

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

Add panic buttons and restricted access to high-risk zones to the emergency department to eliminate delays in security actions (Volonnino et al., 2024).

E

2

Train and educate the staff on de-escalation, conflict management, and crisis intervention to contain the risks of aggressive patients or visitors (Price et al., 2024).

C

To address the root causes present in the sentinel event, several new processes and policies, as well as professional development programs, may be implemented. In order to ensure that all instances of workplace violence are reported and documented to the administration, the standardized reporting system will be used, which will enable the detection of trends and preventive actions in time (Veronesi et al., 2023). The consistency in addressing violent incidents will guarantee that solutions will be created to establish what is expected to be done in the case of any immediate security response, zero-tolerance enforcement, and support of staff with clear, easy, and straightforward policies (Smith et al., 2020). De-escalation training, conflict management, and crisis intervention will be made available to all clinical staff members to provide nurses with the knowledge and skills to deal with aggressive patients or visitors (Price et al., 2024). Besides, the stress management, teamwork, and interdisciplinary communication workshops will help the staff to cope with the high-acuity workload and encourage the formation of interdisciplinary collaboration. All these measures are combined to eliminate a collapse of communication, lack of training, and environmental risks to reduce the likelihood of the appearance of the outcomes and improve the safety of the staff and patients.

The objectives are to enhance patient and staff safety, reduce work-related violence, and improve interdisciplinary communication. The outcomes desired include monthly reporting of incidents, de-escalation-trained employees, prompt security response, well-defined policy, and environmental safety. Months 1-2 policy and reporting development, Months 3-4 staff training, Months 5-6 environment changes, and Months 7 and further drills, workshops, and assessment are suggested as one of the timelines. These activities address the staffing, communication, training, environmental, and policy gaps so as to reduce the recurring incidences and support the safety culture.

There are several organizational resources that can be utilized in order to support the safety improvement plan. They also include the current hospital policies and procedures, which provide the foundation for standardising reporting and security response procedures (Arnetz, 2022). The human resources and clinical leadership can inform, train, and impose the zero-tolerance policies on the staff. It may be done by involving the experienced nursing staff to mentor and provide peer support to other staff on the de-escalation and safe patient care practices (Tikva et al., 2024). Furthermore, the interdisciplinary collaboration with the security staff, administration, and other departments can be used to simplify the existing staffing, communication, and workflow processes to enhance patient safety and staff safety. Through the utilization of these resources, the organization will be able to implement the process of improvement in a manner that will not result in any form of discontinuity in care.