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

Understanding What Happened

After exploring numerous high-acuity patients on an understaffed night shift working in an emergency department, Emily, a 45-year-old nurse, had to face verbal aggression multiple times on the side of one of the patients who had been admitted to the emergency department as well. The aggressiveness disoriented Emily and distracted her, which is why the necessary medication was given only late, and the situation of the patient deteriorated, contributing to further hospitalization.

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?

Most affected was the emergency department nurse Emily, who was forced to withstand verbal aggression of a verbal and threatening nature, which left her nervous and distracted. This nullified her safety and welfare as well as increased her probability of developing stress, burnout, and diminished morale. This indirectly affected the patient since he was kept waiting to receive essential medication, which worsened his condition and increased hospitalization. Such events also put the healthcare organization at risk due to the underreporting of violence and medical errors, leading to the amplified cost through the prolongation of the length of stay, absenteeism, and a potential turnover of the staff (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 human, system, organizational, and cultural factors interplay brought the violent event in the case of Emily to reality. The human factors that predetermined the failure to address the aggression effectively were the exhaustion of the staff members who had to deal with many patients with high acuity and the lack of de-escalation training (Goodman et al., 2020). The understaffing, long waiting time at the emergency department, and absence of a standard reporting system were also considered as system problems that contributed to the problem and made the incident go unreported (Veronesi et al., 2023). At the organizational level, the safety culture was very poor, and the leaders were not involved, which led to a lack of policies to support nurses as they lacked confidence to report the aggression (Arnetz, 2022). It was also caused by such expanded social and cultural problems as the aggression of the family member was also primed by the embarrassment of psychological sickness, drug consumption, and unrealistic expectations of rapid help in the emergency setting (Recsky et al., 2023). All these factors, combined in an interdependent manner, allowed perpetuating the violence in the workplace, which put Emily and her patients in danger.

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 case of Emily, there was apparent disrespect towards the standard practices and safety protocol. Although such ideas as zero-tolerance and promulgation of systematic reporting of workplace violence are developed by national bodies, such as The Joint Commission and the American Nurses Association, these concepts did not find their way into practice (Arnetz, 2022). Most critical steps, including reporting and documenting the aggression of the family member as soon as possible, were not carried out, which is why the administrators did not detect the patterns and implement preventive measures. Further, the lack of formalized de-escalation training also meant that Emily and her co-workers were not prepared to comply with the evidence-based regulations when dealing with aggressive behaviour that was becoming more and more active. These records and instances of compliance failure indicated that nobody paid attention to the incident, and both Emily and her patients were left at a constant risk of damage.

4. Who was involved?:

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

o Supervisors and Managers: Investigate

In the example of Emily, the incident touched upon the participants at multiple levels of staff and leadership. Nurses who worked in the frontline setting were directly impacted since Emily was verbally threatened and intimidated, not to mention that she needed to attend to patients, which also increased the likelihood of error and delays. The physicians were also involved in a very indirect way in as insofar as they approved continuity of care during the disruption encounter. The role of the supervisors and managers, including nurse leaders and hospital administrators, was critical in ensuring safety, but they failed to maintain the safety standards due to the impossibility of enforcing the zero-tolerance rule, failure to maintain the appropriate level of staffing, and lack of resources in the shape of de-escalation training and effective security protocols. Security staff were also included in the list of the principal stakeholders, and when they were absent during the time the incident happened, Emily was left to cope with the aggression by herself and without any direct help. Combined, they resulted in the lack of organized support and control over the leadership that allowed the situation to spiral out of control and put the health of the nurse and the patients at risk (Arnetz, 2022).

5. Was there a communication breakdown?:

o Interdisciplinary Communication: Assess how well different teams communicated.

o Patient-Provider Communication: Explore whether patients were informed and understood their care.

Interdisciplinary communication at the incident was also unsuccessful because the nursing and security personnel did not communicate effectively. Security failed to assist Emily in time. Moreover, the event was not officially reported to the administration because of the lack of a single reporting system, and the leaders could not see the patterns and act accordingly to prevent the issue. This is consistent with workplace violence, where reporting is not done, which prevents coordination of clinical staff, security, and administration (Veronesi et al., 2023). These communication gaps put both the staff and the patients at a higher risk (Tikva et al., 2024). Structured reporting and fast alerts need to be used to prevent the escalation and to ensure patient safety. The communication between the patient and providers was also disrupted since the aggressive family member and high workload probably prevented the patient and the provider from having timely explanations, which led to less understanding and trust. The conditions of stress and staff disorientation are obstacles to effective communication and empathy, which eventually influence the safety and satisfaction of patients (Tikva et al., 2024). It is necessary to be able to organize communication with patients even under high-stress situations so that the care is safe and effective.

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 uninsured status of security coverage, along with the physical infrastructure of the busy and high-acuity emergency department, led to stressful environments, which complicated the process of dealing with aggressive behavior (Recsky et al., 2023). Staffing was also very inadequate since Emily was on duty alone and with some of the high-acuity patients, which put an extra strain on her and distracted her attention. It aligns with data that a large nurse-to-patient ratio has a negative impact on de-escalation and prompt measures (Goodman et al., 2020). Finally, the nurse lacked explicit de-escalation or crisis intervention training, and poor conflict management training has been found to impede the ability of staff to control aggression safely.

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.

The policies and procedures of the organization also contributed to the incident. The lack of a standardized reporting system meant that Emily had not reported the incidence of aggression officially. That means that the compliance with the policy was not complete, and the leadership had no knowledge about the potential safety risks (Veronesi et al., 2023). In addition, the circumstances suggest policy ambiguity and inaccessibility since the employees were not told explicitly how to access emergency security help in case of violent behavior. Without clear or well-utilised policies, there is no possibility of coordinating and introducing timely interventions and mitigating risks to both staff and patients (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.

No, monitoring and surveillance were not successful. The fact that Emily was not concentrated on the activity of handling the aggressive family member, but rather on delivering a vitalized medication. It means that the patient did not get vital signs and patient needs monitoring as fast as it should have been, which, in its turn, worsened the patient (Tikva et al., 2024). Even though the scenario does not specifically involve the alarm, the high-acuity environment and the stress of its residing staff predispose the condition of alarm fatigue or slow response, leading to the lack of adequate staff level and environmental factors that can foster timely monitoring and patient treatment (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 may be learned such that such incidents may be prevented. The systemic changes include a standardized reporting system, transparent and easily accessible policies in which employees can seek immediate security help, which would boost interdisciplinary communication and timely interventions (Veronesi et al., 2023). The training requirements are connected to the provision of de-escalation and crisis intervention training to the nurses and the enhancement of their competence in working with aggressive patients and visitors (Price et al., 2024). Staffing in the high-acuity units to reduce stress and distraction, physical environment including safety tools such as panic buttons and controlled access, and an incident-reporting and incident-learning culture are some of the areas to be improved. The combination of staff education and environmental change, as well as the enactment of the policy, can reduce workplace violence, enhance patient safety, and make the staff better equipped to behave more proactively in the circumstance 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.

Several measures may be employed to make patients safer. The improvement of interdisciplinary communication, adequate staffing, and physical environment modifications comprises panic buttons and limited access to high-risk areas, among others, which is the reduction of risks (Volonnino et al., 2024). Education and training are also required, such as the training of nurses in the rules of de-escalation, conflict management, and crisis intervention practices to be in a position to respond to violent patients or visitors (Price et al., 2024). Besides, the culture of reporting and feedback should be established to document and analyze the incidents and utilize them as a guideline for consistent improvement to ensure that the staff and leadership will learn based on their mistakes and that they will not occur again (Veronesi et al., 2023; Tikva et al., 2024). When combined, these measures can contribute to patient safety, the reduction of mistakes, 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

It was due to the lack of interdisciplinary communication between the nursing and the security staff, and the fact that there was no formal reporting that timely intervention and awareness were not set, and this is one of the reasons why the medication was not given promptly.

HF-C

2

The employee had not undergone specific de-escalation and crisis management courses, and thus, Emily was unable to cope with the violent family member safely, but she became stressed and distracted when delivering care.

HF-F

3

ThThe The emergency department was of high urgency and was overstaffed; thus, the workloads and stress levels were more demanding, reducing the capacity of Emily to monitor patients and respond to the demands.

HF

F/S

4

The unsafe situations that contributed to the run out of the situation included the real-life conditions in the overcrowded emergency department, the absence of security personnel, the panic buttons or locked access, which were all unsafe situations.

E

5

The lack of a consistent reporting system and illegible guidelines on the method to request rapid security aid contributed to the inability to comply with the policy and respond satisfactorily.

R

6

This was not an optimum situation since the risk was aggravated by the fact that the acuity of the patients was high, family members of patients were aggressive, and lacked well-coordinated support systems.

B

The solutions to the issue of workplace violence and patient safety improvement provided by evidence-based methods focus on the various causal factors in the scenario. Structured reporting systems will ensure that the incidents will be recorded, the patterns will be identified, and preventative actions will be performed (Veronesi et al., 2023). The de-escalation and crisis management training would equip the nurses with the information to safely handle aggressive patients or visitors in order to remove any stress and minimize errors (Price et al., 2024). High-acuity unit staffing is also one of the measures to avoid fatigue and timely intervene (Recsky et al., 2023). Such environmental safety precautions as controlled access, the presence of security forces, and panic buttons can be used to reduce the possibility of violent encounters (Volonnino et al., 2024). Enhancement of safety and quality is also encouraged by the presence of transparent policies and a culture that encourages reporting, peer support, and continuous feedback (Tikva et al., 2024). Together, the strategies address the system, human, and environmental factors that encourage the risk of patient killing and injury in the workplace.

The introduction of evidence-based measures might be taken directly to prevent a repetition of such an event, as in the case of Emily. The adoption of a standardized reporting system would imply that there is an official record of aggressive encounters and that the administrators will be able to use security resources more efficiently since they will be aware of the trends (Veronesi et al., 2023; Arnetz, 2022). The nurses would acquire knowledge on how to safely deal with aggressive patients or family members by de-escalating or managing a crisis, and the final result of this practice would be the reduction of stress, distraction, and delayed care (Price et al., 2024). Adequate manpower in the acuity would limit the workload and burnout, meaning nurses could monitor vital signs and intervene at the right time. Environmental safety, in the form of restricted access to sensitive areas, panic buttons, and increased security availability, would help to respond to the aggressive behaviours faster (Volonnino et al., 2024). Finally, clear policies should be created and a culture of valuing reporting, feedback, and peer support should be developed that would guide the staff’s behaviours in case of incidents and would lead to the further improvement of patient safety and avoid harm to the staff (Tikva et al., 2024).

Action Plan

One for each Root Cause/Contributing Factor from above

E / C /

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

3

Keep staff peer support and discussion forums to discuss minor situations in which full elimination or control cannot be achieved, and to reinforce that exposure to aggressive behaviour may happen, but to reinforce awareness and vigilance (Tikva et al., 2024).

A

To address the root causes present in the sentinel event, several new processes and policies, as well as professional development programs, can be developed. In order to ensure that all instances of workplace violence are captured and reported to the administration, a uniform reporting system will be used, which will enable the identification of trends and preventive actions before it is too late (Veronesi et al., 2023). Creating uniformity in responding to violent events, solutions will be established to establish what to do should any immediate security response, zero-tolerance actions, and support staff by developing clear and readily approachable policies (Smith et al., 2020). The training of de-escalation, conflict management, and crisis intervention skills will be provided to all clinical staff to equip nurses with skills and knowledge to approach aggressive patients or visitors safely (Price et al., 2024). Also, stress management, teamwork, and interdisciplinary communication workshops will help the staff to adjust to the high-acuity workload and facilitate interdisciplinary collaboration development. All these are measures that are combined together to counter communication breakdowns, training gaps, and environmental risks to reduce the likelihood of the eventuality of such events and improve staff and patient safety.

These are expected to enhance patient and staff safety, reduce workplace violence, and enhance interdisciplinary communication. The outcomes sought include the routine reporting of incidents, de-escalation-trained employees, a once security response, direct policy, and environmental protection. The policy and reporting development, staff training, environmental changes, and Months 7 and further drills, workshops, and assessment are one of the timeline. Such activities address the staffing, communication, training, environmental, and policy loopholes to reduce repetition and promote a safety culture.

The safety improvement plan may be supported by a number of available organizational resources. These also include the current hospital policies and procedures that provide the foundation of standardisation of reporting and security response procedures (Arnetz, 2022). The human resources and clinical leadership can enlighten, train, and enforce the staff on the zero-tolerance policies. Mentorship or peer support of the other staff can be done through the presence of experienced nursing personnel in relation to the systems of de-escalation and safe patient care (Tikva et al., 2024). Furthermore, the cross-functional collaboration with security staff, administration, and other departments can streamline the existing staffing, communication, and workflow measures with the beneficial effects on patient safety and staff safety. Using these resources, the organization will be able to perform improvements in an effective way that will not cause any discontinuity in care.