Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Basanti Saha

School of Nursing and Health Sciences, Capella University

NURS4020: Improving Quality of Care and Patient Safety

Dr. Stella Barber

April, 2024

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 Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Healthcare settings are very unpredictable. Patients' conditions can change at any time.

Instant intervention is required to prevent adverse effects. Recognizing the contributing factors is

crucial to save a life or prevent complications. Every patient is different and deteriorates

condition rapidly or gradually. Whenever there is a delay in identifying the signs of deterioration,

it can have a direct impact on a patient's outcome. Nurses provide direct care to patients and play

a crucial role in detecting the signs of patient deterioration. Root cause analysis (RCA) is a

process for identifying the causal factors that compromise patient safety (Singh et al., 2023).

Staffing shortages, lack of knowledge and confidence, and the continuous monitoring system are

the possible causes of delayed response. This paper will discuss and analyze the barriers that

cause delays in patient care and include evidence-based practices to present an improvement

plan.

Analysis of the Root Cause

Modern technology has been incorporated into the healthcare system to enhance patient

safety. It has been easier to monitor patients' vital signs and conditions in clinical settings by

using a patient monitoring system. A continuous monitoring system helps to identify the signs of

clinical decline promptly, which reduces the length of hospital stay and cost. In this post-COVID

era, the nursing staff shortage is a problem. A higher nurse-patient ratio increases the workload

for nurses, and as a result, nurses get burned out, which leads to delayed response. Poor nurse

staffing is associated with missed care, missed care is associated with adverse events, and lower

quality of care (Nantsupawa et al., 2021). Nurses usually work for an extended period, which is

straight 12 hours. Towards the end of the day, they are exhausted and getting ready to report to

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the upcoming shift, there is a high chance they will miss the signs of early deterioration, and

something unexpected can happen.

Life-threatening situations such as heart attack, strokes, acute respiratory failure, and

massive bleeding can happen in the blink of an eye. Nurses should have efficient knowledge to

identify the signs of any life-threatening situations and training to act accordingly. The critical

components of identifying early deterioration are monitoring vital signs, EKG rhythm, changing

mental status, and frequent-focused assessments. Sometimes, nurses fail to recognize the signs of

declining health due to a lack of knowledge and training. New graduates are in the process of

transitioning to a professional nurse role. Oftentimes, they are overwhelmed with the workload,

struggling with time management, and learning how to prioritize tasks. The limited exposure and

lack of confidence also cause anxiety and self-doubt. These are the root causes new nurses fail to

address when their patients’ conditions deteriorate.

In this situation, the patient came to the emergency room with abdominal pain, low-grade

fever, nausea, and vomiting. The patient was hemodynamically stable when he went through the

triage. The patient did not complain of any chest pain or shortness of breath (SOB), which placed

the patient in the low acuity group. The patient was not on the continuous monitor as there was

no complaint of chest pain or SOB. One dose of IV pain medication was administered on

admission for pain. After waiting for four hours, transport came to take the patient for CT

abdomen. The patient and family asked for another pain medication before transferring the

patient to the stretcher. A newly graduated nurse came and administered another dose of IV pain

medication. The patient looked a little distressed but had no complaints of chest pain or SOB.

The newly graduated nurse did not take any other actions. After waiting another three hours, the

doctor came up with the result, appendix burst-related sepsis. Meantime, the patient started

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feeling his heart beating fast, SOB, and severe belly pain. The patient informed the nurse about

the current problems. She came after 15 minutes and connected the patient to a cardiac monitor.

The monitor showed a heart rate of 140, respiratory rate of 38, BP - 88/50, and SPO2 - 92% in

room air. No urine output since the patient got into the hospital. The patient went for an

emergency appendicectomy. The patient was transferred to the ICU after the surgery to be

treated for sepsis.

This event affected many people, including patients and families. Hospital staff members

were affected by this event, including the patient’s nurse, the new nurse, and the doctor. The

patient waited a total of seven hours in the ED before the doctor found out the cause of

abdominal pain. If the patient had been taken to the operating room on arrival, this situation may

have been prevented. Waiting a long time due to a shortage of staff caused appendix-burst-

related peritonitis. In addition to a staffing shortage, a lack of knowledge and assessment of

patient condition change failed to recognize early deterioration. The new nurse noticed the

patient looked distressed but did not do her focused assessment. This event could have been

caught earlier if the patient had been on a continuous monitor.

This situation could have been better in a few ways. Instead of sending the new nurse, the

lead nurse should have come and assessed the patient when the patient asked for another pain

medicine. When the nurse administered the second dose of analgesic, the patient was in distress.

The new nurse should have communicated to the lead nurse or the doctor about distress. The

transport people should have come earlier to take the patient for the CT scan. The doctor should

have reviewed the results upon completion. There are controlled and uncontrolled factors. The

controlled factor is the new nurse. It is been two months since the new nurse got off orientation.

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She only did what the patient asked and did not perform a focused assessment. The uncontrolled

factor is the triage assessment, which is based on the first come first serve and the acuity level.

Application of Evidence-Based Strategies

Retaining the regular staff and recruiting new staff is the primary goal to increase job

satisfaction and patient safety. The nurse manager and leadership should collaborate with other

nurses to develop a better workplace to provide the best patient care without stressing the nurses.

Being realistic and developing achievable goals is the first key. A healthy workplace increases

job satisfaction. Healthy work environments that maximize the health and well-being of nurses

are essential for achieving good patient and societal outcomes, as well as optimal organizational

performance (Mabona et al., 2022). A healthy workplace can improve productivity, job

satisfaction, and staff retention. Job satisfaction is related to an optimal level of patient care.

Nursing is teamwork. When needed, nurses should ask for assistance. They can call the charge

nurse or their peers for help. If a nurse gets stuck in a room with a patient and the other patient

needs help, calling for help is the best way to address this issue.

To respond appropriately in life-threatening situations, nurses must have the necessary

knowledge and training to recognize the signs. New graduate nurses are transitioning to their new

roles and may find it difficult to adjust to their new responsibilities due to the gap between nursing

knowledge and abilities required in the practical field. New graduate nurses often need frequent

training to enhance their capability to evaluate patients with complex problems and identify the

care they need instantly. Inter-professional education provides new graduate nurses an opportunity

to boost their hands-on capacity, as well as practical skills to enhance confidence in patient care

(Yeh et al., 2022). Inter-professional collaboration is another key to communicating patients’

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conditions with other healthcare professionals. New-grad simulation training will enhance the

nurses’ confidence to identify the signs of adverse events and respond promptly.

Technological innovation is improving quality care. A continuous monitoring system

monitors heart rate and rhythm, blood pressure, respiratory rate, and saturation rate, which is part

of early warning signs. Continuously monitoring these vital signs leads to earlier detection of

deterioration (Peters et al., 2023). This machine monitors heart rate and rhythm for 24 hours and

detects the early signs of any cardiac abnormalities and cardiac arrest.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Lack of staffing can lead to poor healthcare services for people. Teamwork and

collaboration are important in a healthcare team (Mabona et al., 2022). The nurse manager and

HR should work with the staff to implement strategies to increase staff retention, such as higher

wages, incentives, schedule flexibility, rewards and recognition, improving the work environment,

and addressing nurses’ issues as needed. Conduct an exit interview to find out why the nurses are

leaving. The recruiters should conduct more job interviews at local community events and nursing

schools to hire more people.

Before executing any new policy or skill, education is necessary to achieve the

organizational goal. Implementation of inter-professional training is necessary to make sure all

healthcare workers are on the same page and aware of the expectations. New grads are

transitioning to practice. Additional simulation training will enhance confidence and skill in patient

care. Simulation-based teaching improves inter-professional communication skills and work

satisfaction, increases understanding of other healthcare professionals’ responsibilities, and

promotes critical thinking (Yeh et al., 2022). Feedback from the staff helps to find out the pros and

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cons. Questionnaires are a great strategy to collect data on what, why, and how things can be

changed or modified.

Patients with conditions such as sepsis, irregular heartbeats, drug abuse, sleep apnea, or

respiratory disorders, where vital signs are prone to fluctuations, may experience deterioration

sooner rather than later. As an example, at the beginning, a patient with sepsis shows a high heart

rate and respiratory rate and begins to get worse until receiving the first dose of antibiotics.

Continuous monitoring helps the healthcare worker track down the trending vital signs. Patients

can have continuous external monitoring by implementing remote monitoring. Remote monitoring

would benefit in detecting any cardiac dysrhythmia. Continuously monitoring vital signs remotely

in patients leads to earlier detection of deterioration, reduction of nurses’ workload, and reduced

cost (Peters et al., 2023). Continuous remote monitoring of vital parameters reduces morbidity

and mortality in hospitals ( Rajanna et al., 2023).

The main goal is early detection of the signs of clinical deterioration. Continuous

monitoring would need clearance from a quality control team to apply proper policies and create

an algorithm for the patient. The finance team needs to approve enough budget to monitor

everyone regardless of their problem. The education team needs time to plan and organize

appropriate training. HR and nurse manager need to collaborate to raise pay or bonus or

incentives. The recruiter needs to hire more nurses. Even though the goal is reducing patient

deterioration, implementing the process into practice could take longer.

Existing Organizational Resources

All staff members who provide care for a patient are responsible for recognizing patient

deterioration. To successfully implement the plan, the interdisciplinary team, the quality

improvement team, finance manager, HR, and the hospital incident management team will

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collaborate to process the improvement plan. Additional resources like hospital policies and

protocols are great for providing optimal levels of care and maintaining patient safety. Telemetry

is a remote monitoring system to identify the early deterioration of a patient's condition. Utilizing

existing resources reduces the overall cost and guarantees little disturbance to continuing patient

care.

Conclusion

Nurses play an important role in patient safety. They are a vital component of the

interdisciplinary team and the first ones who notice whether patients’ condition improves or

deteriorates. Implementing evidence-based solutions such as continuous cardiac monitoring,

inter-professional training, increased staff retention, and recruiting new staff can improve

situational awareness and patient safety.

References:

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Rajanna, A. H., Bellary, V. S., Puranic, S. K., Nayana, C., Nagaraj, J. R., Eshanve, D.A., &

Preethi, K. (2023). Continuous Remote Monitoring in Moderate and Severe COVID-19

Patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10544857/

Mabona, J.F., Rooyen, D.V., & Ham-Bayoli, W.T. (April 25, 2022). Best practice

recommendations for healthy work environments for nurses: An integrative literature

review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9082217/

Nantsupawat, A., Poghosyan. L., Wichaikhum, O., Kunayiktikul, W., Fang, Y., Kueakomoldei,

S., Thienthong,H., & Turale, S. (2021). Nurse staffing, missed care, quality of care and

adverse events: A cross-sectional study.

https://doi-org.library.capella.edu/10.1111/jonm.13501

Peters, G. M., Peelen, R. V., Gilissen, V. J., Koning, M. V., Harten, W. H.& Doggen, C. J. (2023)

Detecting Patient Deterioration Early Using Continuous Heart rate and Respiratory rate

Measurements in Hospitalized COVID-19 Patients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9871416/

Singh, G. Patel, R. H., & Boster, J. (2023). Root Cause Analysis and Medical Error Prevention.

https://www.ncbi.nlm.nih.gov/books/NBK570638/

Yeh, S., Lin, C., Wang, L., Lin, C., Ma, C. & Han, C. (2022). The Outcomes of an

Interprofessional Simulation Program for New Graduate Nurses.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9653773/#B12-ijerph-19-13839