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

Understanding What Happened

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?

Mr. Robert Miller is a patient in a medical-surgical unit, who had a bowel surgery, for which he had been admitted to the medical-surgical unit previously, without discharge education, for a major adverse event. He was not given a substantial education on the amount of medication that he should take, wound management, and how he was supposed to be after leaving the hospital, and there was no official to provide him with what he was being informed.

The misconception in the care of the dressings and in the administration of medicines during the discharge even resulted in a surgical site infection and re-hospitalization. The work system in the medical surgical unit is very critical in the context of patient education and indeed, as evidenced in the case, is the direct outcome of the lack of gaps in the discharge preparations, which is the immediate result of the poor recovery and safety of patients.

1. Why did it happen?:
   • Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.
   • Society/Culture: What role might cultural assumptions or backgrounds play?

There were a variety of causal factors, and these took place on the human, system, and organizational platforms. On an individual level, a high ratio of patients to nurses did not leave much time for nurses to deliver a productive and valuable education, and the risk of giving instructions that are less than complete and/or missing (Kakemam et al., 2025). On a system-wide level, it was not always possible to have standardized discharge teaching procedures as well as systematic approaches to teaching (such as teach back), which were not always part of the working flow.

The importance of the role of patient education as a successful strategy for moving towards safety was not sufficiently addressed at the structural level, and leadership in relation to funding of the continuous training was weak. The rushed discharge teaching, which was one of the normalised forces of cultures over time in the unit, and a halfway done teaching now emerged as a unit practice, a safety issue.

1. Was there a deviation from protocols or standards?:
   • Procedures and Policies: Determine if established protocols were followed or if there were deviations.

This was a sign that during the discharge of Mr. Miller, there was a uniformity in terms of the teaching standards he was recommended to adhere to and actually did. While general discharge instructions were being prepared, information on how to have safe self-care at home wasn’t provided in a comprehensive way, and the patient’s understanding had not been clarified as required by the best practice guidelines.

The instructions were provided without an exam to make sure that the patient has adequate knowledge on how to take medicine, or how to maintain the wound. The medical record write-ups do not record what activities within the lesson have been performed and what reinforcement and/or clarification have been provided (Atinga et al., 2024). These types of failures are indicative of systems or processes failure, and not an individual provider.

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

It was found that the situation of this negative phenomenon was influenced by the organizational policies. Although certain general policies have been related to discharge education, there was no reference to how exactly the very process of teaching should be carried out, what documentation should be done, and what normative expectations should be viewed on what is to be expected in regard to accountability. These policies and the availability of the latest guidelines were not informed to all its staff, neither was a perfect condition, therefore leaving the implementation of these policies as poor from one shift to another.

The review process of the policy was also an unusual one and did not anticipate that the amendments necessary by virtue of the recently discovered evidence-based solutions (Moradi et al., 2024) could be implemented and result in a shift in the teaching processes. This resulted in a practice variability, where no patient would have had an expectation that such could be brought about, and would have led to the eventual risks and injury to patients that would have been avoided.

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.

Yes, we had a communication breakdown. The interdisciplinary communication was minimal, and no follow-up of such frameworks as SBAR (Situation, Background, Assessment, Recommendation) and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) was provided. It caused Mr. Joey Lee a higher risk of falling and mobility restraint during handovers of shifts. The patient-provider communication was also poor, as Mr. Lee may not have comprehended the need to seek help prior to ambulation in all its essence. The explicit repetitive messages related to the threat of falls and the safety expectations would have reduced the risk of biased movement to a minimum (Howick et al., 2024). There was poor communication between the Bedside Nurse and the Pharmacist who reported the dizziness risk.

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.

There were some contributory factors. The physical environment was not always helpful in providing safe movement, as the assistive devices could not be available immediately, and bed alarms could not be activated. The physical environment, such as the flooring, was shiny and was not coated with a non-slip coating. There was also the need to provide the patient with adequate lighting in his room, which was not suited to accommodate a nighttime post-surgical patient with limited mobility.

The factors that contributed to the fall of Mr. Lee are the lack of mobility, the use of sedative medications, and an insufficient level of support. Other elements that contribute to the possibility of preventable accidents are staffing shortages, a deficiency of communication among the shifts, and inconsistent compliance with existing safety practices (Moriwaki et al., 2025). Staffing was also strained, and the nurses were not in a position to attend to the needs of patients promptly.

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.

The policies of an organization are an important factor. M. Lee had fall-prevention policies, which were not consistently set and backed by auditing and feedback. Other policies were not clear on how frequently a reassessment is done, and the responsibility of seeing that the safety interventions are still in place was not fulfilled (Turner et al., 2020). This non-compliance affected compliance and reduced preventable falls. The hospital has policies and those set by the health department that are accessible and fully available to all the medical personnel.

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.

There was no effective monitoring and surveillance of this incident. The risk of falls was identified in Mr. Lee, but the close monitoring of his mobility status and the results of taking medication was not performed. The absence of active bed alarms and the time it takes to react to the movement attempts made this fall possible. An increased level of monitoring would have promoted early intervention (Zhu et al., 2025). The alarm fatigue and poor staffing contributed significantly to this incident.

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

Safety is not personal property. It is possible that the fall rates could be reduced to 11.33 and 16.25 per 1000 bed days with the help of AI-based surveillance. This case will show the value of the periodicity of fall-prevention measures and risk re-evaluation (Danial et al., 2025). Interdisciplinary frameworks are also crucial in the creation of improved outcomes in the long run. Handovers can be improved with interdisciplinary models such as SBAR and TeamSTEPPS to have better communication and coordination and improve patient outcomes. Redesigning the systems should be focused on empowering staff training, stable operation of safety equipment, and effective communication in case of handover (Matzke et al., 2021). The focus of quality improvement efforts needs to be on proactive screening of high-risk behaviours and responsibility regarding preventive actions. Advanced technology and the use of alarms are usually involved in quality improvement.

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.

This enhancement of the degree of safety can be achieved through substituting manual risk assessment with AI-CDSS (Artificial Intelligence Clinical Decision Support Systems), which implements real-time information to forecast falls with an average general accuracy of 73-percent. The individualization of fall-prevention plans, enhancement of the nurse-to-patient ratio, and proper utilization of monitoring equipment can contribute to patient safety. The evidence-based fall-prevention practices should be strengthened in regular training.

A non-punitive culture of reporting should be encouraged so that the staff is able to report at all times, and that will also help minimize such incidents. It will also enable the organization to learn and keep on improving patient and nurses’ communication (Forde‐Johnston et al., 2022). The feedback from the family of the patient will also help in minimizing the communication gap between the patient and nurses. Both open and effective communication, as well as effective staffing and equipment management, are the key to early risk detection.

Root Cause– the most 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

Inadequate supervision causes a risk of falls for the patient.

Inconsistent application of the fall prevention protocol

Insufficient training in alarm prioritization and management

1

Inadequate staffing levels and ineffective communication caused intervention.

ü

ü

2

Shift handoffs lacked specific mobility and medication side-effect data.

ü

ü

3

Lack of staff competency in utilizing electronic risk assessment tools.

ü

ü

The most common causes of inpatient falls are: poor risk evaluation, intermittent adherence to preventive precautions by the staff, and unsafe patient care environments. According to Guirguis-Blake et al. (2024), patient-centered fall-preventive measures based on fall mobility, medication interactions, and fall history may lead to a significant reduction in inpatient fall rates and fall-related injuries.

The Agency of Healthcare Research and Quality (2022) recommends evidence-based measures, including nurse staff training, the best nurse-to-patient ratios, frequent use of bed alarms, and mobility support equipment, as a combination of preventive measures against falls. As Roderman et al. (2024) also pointed out, routine environmental safety measures, such as clear walkways, adequate light sources, and wearing non-slip shoes, are imperative interventions that minimize the risk of falls among hospitalized patients even more. The regular retraining of the staff and its competence may help to sustain these strategies and minimize unnecessary harm, decrease the length of hospital stay, and lessen the usage of extra treatment.

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The hospital will install a Human-Centered Artificial Intelligence Decision Support System (AI-DSS). This system will track the medication, orthopedic sedatives, and the post-operative status of Mr. Lee in real time and send a “High Risk” notification to the mobile phone of the nurse. This replaces the updates in the Morse Fall Scale, which could easily be forgotten, as in a manual. The regular applications of bed alarms and mobility aides’ protocol in the case of Mr. Lee would have helped to avoid unassisted ambulation, as it was delayed before the employee fell. The compliance with safety instructions should have been enhanced by reinforcing the patient education related to the risk of falls and medication effects (Firda Rahmadani et al., 2025). The interdisciplinary communication would be carried out during the shift changes and ensure that all team members were aware of their risk status. Nurses would conduct the preplanned rounding to assist the patient in toileting, pain, and mobility needs and make them less inclined to walk on their own or herself (Alikari et al., 2022). Sharing of information about his mobility constraints would be known to all the team members through interdisciplinary communication during shift change. Together, they would help to provide timely interventions, prevent unassisted ambulation, and minimize the risk of a repeat fall.

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

 Implement Artificial Intelligence electronic health record fall-fight dashboards for Observation and Surveillance.

C

2

Make the normalization of handovers related to all post-operative shifts. 

C

3

High-friction non-slip floor resins should be installed.

E

The Pharmacy-Nurse Safety Check of all high-fall patients on the high-fall-risk medications will be part of the implementation of a new policy. Simulation-Based Training on alarm management will also be used as part of professional development to decrease desensitization and better reaction to critical bed alarms. The company will revise the fall- prevention policies to impose the use of active safety equipment and regular risk assessment (Wang et al., 2024).

Every quarter, the employees will receive three training sessions on how to know about the risks of falls, educate patients, and scan the environment. Routine audits shall be used to check the compliance of the monitoring (Höglander et al., 2022). The few guidelines were given on responsibility to test the functionality of bed alarms and other safety appliances, and it will undergo a total overhaul by coming up with new guidelines on patient safety and care. The overall loopholes will be reduced with new reforms.

The key goals are to reduce inpatient falls, to improve patient outcomes, and to minimize the costs associated with them. The main aim is to increase the confidence of the patients and provide more security in their mobility within the hospitals. The improvement of the responsiveness of nurses to the needs of patients, the frequent use of fall-prevention devices, is also on the agenda. Through evidence-based fall-prevention programs, a reduction in the inpatient fall rate by 20-30% is achieved in 6-12 months. The initial three-month phase will involve educating and retraining the staff on the use of standardized fall-risk assessment tools, and the result of the intervention is anticipated to be at least 90% adherence to fall-risk documentation and prevention interventions (Agency for Healthcare Research and Quality, 2024).

The improvement in nurse responsiveness, frequent use of the fall-preventive measures, and patient education should reduce the number of falls by at least a quarter within six months. Seven to eight months later, the fall monitoring technology, with the help of artificial intelligence and staff re-certification, should result in another 10-15% fall reduction, as surveillance with the aid of technology will lead to an improved rate of identifying the risk of falls (World Health Organization, 2021). The long-term objective of this plan is to reduce zero falls resulting in severe injury or fracture by ensuring strict performance checks, an annual employee competency review, and reviewing the annual policies to comply with current best practices within 12 months.

Our Health Informatics Team will need to build the AI- DSS in the existing Cerner / Epic system. The Clinical Education Department should help in conducting the workshops on reducing attempts at alarm fatigue. The Environmental Services ought to regulate the material arrangement of the non-slip floors and enhance lighting. The existing resources include the clinical education department, quality improvement teams, and the interdisciplinary care staff.

Nursing leadership and unit managers are important as they ensure sufficient staffing in all sectors, ensure that compliance with safety policies is encouraged, and inculcate a non-punitive culture in reporting culture (Miura & Kanoya, 2025). The interdisciplinary team members, including the physical therapists and pharmacists, can help to add mobility planning and drug review. The resources available will come in handy in improving the fall-prevention activities, without necessarily engaging in huge additional costs. Responsibility of training, monitoring, and consistent enhancement of fall-prevention activities will be achieved through the use of these resources.

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.