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

Understanding What Happened

1. What’s the story here?

Start by figuring out what happened first to lead up to the sentinel event.

o Collect background details of the incident, such as who, what, when, and how.

o Who was the problem/event directed at and how?

A 68-year-old Mr. James Carter, who was recuperating in the intensive care unit after cardiac surgery, had a sentinel event, whereby an episode of ventricular tachycardia (VT) was missed. This caused a cardiac monitoring alarm to trigger, an alarm that the nurse working with him was not able to hear due to the number of harmless alarms heard.

An example of such negligence is failure to promptly recognize his emergency, leading to cardiac arrest, hypoxic brain damage, and eventual ongoing neurological dysfunction. It revealed that the alarm responses were very poor within the ICU.

2. Why did it happen?

• Human Factors: Determine if communication problems, fatigue, or insufficient training were factors.
• System Factors: Consider workflows, system failures, and environmental considerations.
• Organizational Culture: Identify whether there are cultural issues, a lack of safety culture, and a lack of leadership support.
• Society/Culture: How may cultural assumptions/backgrounds be a factor?

This event was seen to be caused by human, system, and organisational factors. In fact, at the human level, many false alarms of low priority occurred, causing the nurse to become alarm fatigued and also decreasing her response (Salameh et al., 2024). From a systems point of view, the alarm system lacked any means of prioritizing the alarms, and consequently, there was no way to determine which were pivotal and which were routine alarms.

Organizational domains included: lack of leadership attention to alarm safety, a reactive approach to safety (as opposed to a proactive approach), and no formal training on alarm management. Moreover, alarms were beeping continuously to accompany the high-pressure environment of the ICUs, negatively affecting the responsiveness of the staff members. Finally, the problem of desensitization was maintained by practices that occurred in the workplace, which found it normal to have frequent alarms.

3. At what point was there a deviation from protocols or standards?

• Procedures and Policies: Identify whether or not the procedures and policies were adhered to or deviated from.
• Are there any that did not occur or did not occur as planned?
• Documentation: Examining their medical records, nursing notes, and any other pertinent records.

Alarms management, clinical standards, and protocols were obviously not adhered to. Alarms were on but not directed at the problem with Mr Carter, and were not checked with the necessary urgency. Policies on alarm setting and response processes were either unclear or not followed, and the best practices in ranking and escalation of alarms were not followed (Dee et al., 2022).

Records of alarm trends, ‘alarms set,’ and response times were not available for all patients, which makes it difficult to detect or prevent alarm fatigue. Mistakes are a function of failures in the system, not of individuals’ errors in staffing.

4. Who was involved?

• Staff: Who are the roles of people directly involved in the event?
• Investigate (Supervisors et Managers)

The responsibility for Mr Carter’s alarms is with the nurse who has the primary responsibility for him. But the ICU supervisor and unit manager are equally culpable since, not only did they not take the necessary steps to make sure guidelines were being met for response to alarm, they did not verify adherence to guidelines by staff.

Leadership did not give proper policy support or training to avoid the occurrence of such incidents (Dee et al., 2022). In addition, there were no mechanisms in place for escalation of unanswered critical alarms or to look at the alarm response rates of staff members.

5. Was there a breakdown in communication?

• Interdisciplinary Communication: Review the level of interdisciplinary communication.
• Patient-Provider Communication: Inquire about patient awareness and understanding.

A failure in communication was a key factor in this sentinel event. There was a hindrance in communication between interdisciplinary working groups, and the system was lacking in reporting abnormal cardiac rhythms in time, for example, the lack of a formal system such as SBAR (Irawati et al., 2025).

Communication with the health care providers was also poor. Mr. Carter and his family were given no education in the importance of alarm systems and how alarm systems work to give him confidence to help him alert others for a change.

6. What were the involved aspects ?

o Physical Environment: Take into account facility layout, equipment available, etc., and Staffing Levels.

• Training and Competency: Evaluate staff Knowledge and Skills.

The first was the physical environment, and a number of causal factors were culled. The one thing that made the ICU not a quiet space (and noisy and hectic) was multiple alarms emanating from various monitoring systems. Staff levels in these were also low, and a nurse was able to administer treatment to some of the more high acuity patients, potentially raising the risk of desensitisation as well as possible misinterpretation of appropriate responses to the alarm.

Burnout in the caregiver was also attributed to the workload pressure, as well as a failure of, and/or reduction in, discriminating between meaningful and meaningless alarms. Alarms were a major cause for concern due to inadequate training and competency in handling the alarms. There is no training on current alarm recognition, priority, and response, nor have team members practiced simulation exercises on real alarm situations (Dee et al., 2022).

8. Have any organizational policies or procedures played a role?

o Policy Compliance: Determine whether or not policies have been followed.

o Policy Clarity: Evaluate the clarity and accessibility of policies.

This was also greatly affected by institutional policies. There was a lack of clear and enforceable guidelines to describe what trigger levels are, which alarm levels are most critical, and what triggers the alarm escalation process in the hospital (Dee et al., 2022). The current policies were not effective at communicating and/or were not consistently applied. Also, no methodical policy review was performed to stay abreast of any changes taking place in technology or within the needs of patients.

9. Did monitoring or surveillance of it fall through?

o Vital Signs Monitoring: Was there any change in Vital Signs?

o Alarm Fatigue: Discuss whether or not alarms were ignored.

In those areas where there were surveillance systems, there was a failure in surveillance. The alarm was activated but not responded to due to Alarm Fatigue. No checks or feedback on the alarms were kept because they were ignored; the alarm was not programmed separately. This was not only because the patient was not monitored at the optimal time, but also because the patient was put at risk of harm, which could have been avoided.

10. What are the lessons to be learned from this to avoid future repeat events?

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

o Quality Improvement: Think about taking action to prevent problems.

The root of the issue that this sentinel event is alarming is that a fundamental change in the approach to alarm management is needed. Going beyond just saying that staff are suffering from “alarm fatigue,” however, is seeing it as a system design issue. For a proactive future with an organization’s safety culture, be mindful of alarm setup, have good procedures, and have ongoing, competency-based training. Additionally, completing interdisciplinary tools such as SBAR and taking an active stance in problem-solving deviance are all important. A single approach combines using tiered (e.g., color-coded) alerts, individualized alerts (based on patient), and auto-escalation of unanswered alarm notifications (Gani et al., 2025). Further enhancement could be achieved by implementing intelligent alarm systems that work on an electronic health record (EHR) platform, which would allow for greater alarm specificity and further reduction of extraneous noise.

11. What can be done to improve patient safety?

o Risk Mitigation: Identify ways to reduce risks.

o Education and Training: Make sure that staff are trained.

1. Reporting and Feedback: Promote freedom of reporting and learning from error.

Patient safety is a systems problem and will require addressing risk minimisation, system design, and workforce skills, among others. Alarm parameters should be tailored to each patient; the contents of “escalation” should be clear and well thought out for the most serious alarms. Alarms are synchronized with the most up-to-date patient information as the real-time data from the patient’s clinical units is presented. There should be good positioning of monitors, background noise should be minimised, and alarms should be audible and easily readable. Being able to respond quickly to determined alarms, as well as maintain an appropriate nurse-to-patient ratio, can also help alleviate cognitive burnout (Rossum et al., 2023). Training should be ongoing and include the following: what an alarm is, how to deal with an alarm, the issue of alarm fatigue, and the progressive and escalated transfer of technical issues to biomedical staff. Continuous safety is a key, and reporting with a non-punitive mentality is a key to a culture. Healthcare professionals should feel free to make error reports of issues relating to alarm and near-miss events. Leaders should strive to use every report as an organizational learning event and then share knowledge using feedback channels like safety briefings, performance dashboards, etc. Open and transparent communications in shift handover and team meetings support early risk identification, trust building, and are an ongoing step towards optimizing safety.

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

Excessive non-actionable alarms leading to alarm fatigue

Insufficient training on alarm prioritization and management

Weak alarm management policies and a lack of enforcement

1

High frequency of false/non-critical alarms; overwhelming auditory noise level

ü

ü

ü

2

Lack of training; no routine competency assessments

ü

ü

3

Outdated/vague protocols; absence of audit, feedback loops, and policy updates.

ü

ü

Alarm fatigue can be caused by the number of alarms that must be dealt with, the incorrect leveling of the alarms, or the lack of adequate support for clinical decisions. In a highly alarmed environment, Li et al. (2023) noted that having “intelligent management strategies” like advanced alarm systems could help to minimize the number and duration of real and nuisance alarms. This will improve the response time of the nurses to critical alarms and will also give them a means for not experiencing alarm fatigue.

The key to effective alarm management is to implement a set of evidence-informed strategies, including staff education, alarm policy and procedure, and reducing unnecessary patient monitoring, according to Dee et al. (2022). Finally Fujita & Choi (2020) had proposed customized alarm parameter protocols, because factory set one fit for all alarm parameters elicit noise and thus the sensitivity of the alarm by the staff is lost.

In Mr. Carter’s case, if a smart alarm system were used, repetitive alerts (such as sharp to heart rate) that are not medically relevant would be screened out, and only a high urgency signal entering the fence would alert the nurse of a true VT where her focus needs to be. At the same time, an individualized parameter protocol set Mr. Carter’s VT threshold to 130 bpm (which is below the default) and allowed daily, interdisciplinary reviews to change the thresholds according to Mr. Carter’s postoperative status, keeping the number of non-actionable alarms to a minimum and maintaining their clinical relevance. Indeed, Nyarko et al. (2023) suggested that if there was regular education given to the staff members, the nurse would have been confident enough and would have eventually developed the “muscle memory” needed to respond quickly with discrimination of the type of alarm in the congested ICU environment. Further, the responsibility and role of persons on alarm being given is clearly defined, and alarm management has clear guidelines, thereby creating a standard and responsible alarm handling procedure. Having a formal process in place for ‘ramping up their response’ for any unacknowledged critical alarm would have added a level of safety to ensure that if their nurse was ‘hit and run’ with a critical alarm (as happened with Mr Carter’s critical alarm in this case), a backup response would have been activated later.

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

Eliminate non-intelligent alarm hardware by replacing legacy monitors with smart alarm systems.

E

2

Control through comprehensive alarm response training for all ICU nurses.

C

3

Control by updating alarm-management policies to require individualized threshold setting.

C

The hospital is going to have new procedures and training, but will focus on the safety of the alarms — sentinel events have happened in the past relating to alarms, and staff response to an alarm will improve. In the first place, the ICU will still be taking the old monitors and replacing them with smart alarms that will have real-time trend analysis and machine learning algorithms to eliminate unimportant alarms and only allow alarms for clinically important ones (Li et al., 2023). The ICU nurses would then be provided with periodic training and a set of varying practical ‘What If?” exercises to practice how to recognize and respond to various alarms.

These sessions will be geared towards training employees to determine if a true emergency or an assumed or nuisance alarm is occurring, as quickly as possible. Further, the hospital’s alarm-management policy will be adjusted to the patient by asking for an individually set alarm threshold at the time of admission to the ICU, and daily review rounds (Dee et al., 2022). At the annual competency checks, it will be a whole different world. The policy is to be implemented using mandatory in-service education sessions.

These are done to ensure that the alarm fatigue can be reduced, the response time of a nurse can be shortened, and injury caused by unanswered alarms can be prevented. The smart monitors will be used to cut in half the number of alarms (from daily alarm log reports) on cardiac ICUs within 6 months of installation. The training and education program, together with changes in policies, will be introduced to a small group of nurses by month 3, but to the entire group by month 12, while they hope to reduce the critical-alarm response times by 40% or more (Dee et al., 2022).

Meanwhile, compliance audits will be conducted to verify that compliance with 90% of patient monitors programmed to include individualized armpits is achieved. Progress will be monitored, and quarterly de-briefs will be performed to identify the barriers early and to allow fine-tuning of the policies as appropriate to ensure events like the missed VT alarm by Mr Carter will not occur again in the next year as a result of the above combination of policies.

The hospital has many helpful resources available that have proven to be impactful and can be used as effective tools to accelerate and aid in alarm-safety plans. One, the development of the new monthly and quarterly alarm drills is easy, and will be readily integrated into the clinical education department’s existing program – no need to hire outside trainers. They will help with hardware and EHR integration, and working hand in hand with the biomedical engineering and information technology (IT) services will ensure smart alarm software is successfully installed and applied on monitors quickly and easily (Javaid et al., 2024). 

Nursing leadership and influential nurses in the units can support and encourage the use of the individual threshold protocols. Finally, the learning surrounding Mr. Carter’s sentinel event can be used to inform updated policies by the risk management/patient safety office and can assist in establishing a just culture to promote an ongoing reporting culture and continuous improvement. These departments can be engaged, and through them, a robust and cost-effective safety program can be implemented that will endure for many years due to their direct tie-in to clinical education and biomedical engineering/IT.