NURS-FPX4035 Assessment 2

NURS-FPX4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.

Root-Cause Analysis and Safety Improvement Plan

Capella University

Prof.

NURS-FPX4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

Date

Category	Details
What passed off?	A homeless diabetic 45-year-old with intractable diabetes, Michael Carter, came to the ER with gangrene contamination of his foot. Due to the ERs being busy and degrading their triage tiers to decrease priority cases to put off, he was once considered low acuity and waited over eight hours for remedy. At presentation, his infection had superior and necessitated hospitalization and amputation of the posterior 1/2 of his foot. Michael had already seen the ER on numerous occasions for diabetic trouble. However, housing instability and lack of transportation prevented him from complying with visits. His case illustrates tool failure in triage, continuity of care, and socially beneficial aid for homeless sufferers, resulting in avoidable adverse final effects. Specialized triage protocols, advanced discharge-making plans, and better integration of social offerings can also prevent this.
Why did it rise?	Michael’s negative stop-surrender result was caused by human, gadget, organizational, and societal problems. ER overcrowding, which was in part due to homeless individuals getting into the ER to get treatment of remedies for chronic infections, caused delays in care. Homeless sufferers lack access to healthcare aside from getting access to the ER as their port of entry to healthcare, owing to impediments to preventive fitness care (Vohra et al., 2022). The ER body of human beings, with these heavy-assed officials, was no longer able to care for the persistent and acute sickness in homeless sufferers. The underlying reasons for such limitations include lousy jogging environments, excessive workloads, and confined education in social homelessness dynamics. Device inefficiencies, alongside facet no longer on-time triage and terrible social employer coordination, restrained powerful care. Wider socioeconomic situations, i.e., financial instability and homelessness, furthermore impacted Michael’s use of the ER, perpetuating bad fitness consequences (Franco et al., 2021).
Deviation from Protocols	There are no health facility guidelines for homeless sufferers, resulting in inconsistent care. Most centers no longer record homelessness inside the medical chart, and as a result, there are coordination gaps in care and no noted opportunities for follow-up (Garg et al., 2021). Michael’s situation is a great example of strategies; disorganized documentation and discharge-making plans bring about fragmented care. Homeless sufferers may additionally lack the right of access to preceding medical records, and consequently, organizations can not accept difficulty displaying diagnoses, treatment, and medication adherence. The one’s protocol deviations result in avoidable headaches and repeated hospitalization.
Who was involved?	ER physicians, nurses, and social workers have been part of Michael’s care. However, restricted assets prevented full assistance. Health facility directors form recommendations that respond to homeless care but will be predisposed to overlook prioritizing primarily based interventions (Burke et al., 2022). Homeless advocacy organizations, municipal officers, and public health agencies also worry about guidelines shaping healthcare disparities. More coordination amongst those activities is integral to getting admission to care and reducing unnecessary ER utilization.
Breakdown in Communication	Insufficient coordination among ER personnel, social personnel, and discharge planners brought about care discontinuity. Most homeless patients are not fitness literate, and as such, they are now not capable of recognizing discharge instructions (late.ková et al., 2025). Michael was discharged domestically without a follow-up plan, resulting in deteriorated health effects. Horrible communication between the diverse healthcare experts and network, going out-of-area possibilities for care, and inappropriate placement of up-discharge care. Homeless patients are difficult to have an impact on because of literacy constraints, intellectual disability, and cynicism in the direction of the scientific device that similarly hinders adherence to care.
Contributing Factors	Training and Competency: ER overcrowding translates to risky exercise settings, extended waits, and substandard patient care, such as Michael’s. Provider delays and burnout are added by a large body of people, which is more than the healthcare device, as Lateková et al. (2025) suggested. The emergency ward’s bodily infrastructure had overcrowding, a lack of consultation rooms, and inadequate diagrams to cope with homeless sufferers like Michael with smooth hygiene requirements like showers and restrooms. The body of workers’ deficits brought about advanced emergency care and insufficient backup for homeless sufferers’ social needs, which added approximately prolonged medical care and suboptimal discharge follow-up. The majority of healthcare personnel are also poorly knowledgeable in handling homeless supatientswhich creates inequalities and horrible consequences.
Organizational Role	There are no standardized tips in the general public hospitals to address the healthcare desires of homeless patients, including Michael, which creates uneven care. Personnel are hindered by a lack of resources and approximately no net regarding hyperlink sufferers to preferred offerings. Disconnection is a motive of health disparities and heightens the capability for repeated ER visits, as studied through the technique of Lateková et al. (2025). Regularly taking place, emergency response hints achieved for acute care settings posed coverage compliance stressful situations as they did not explicitly encompass contemplated photographs on the repeating health desires of homeless sufferers that delivered approximately not unnoted care opportunities and unequal aid allocation. The policies already in place for social issuer referral and discharge planning can no longer be completed efficaciously because of an inadequate group of workers’ abilities or affected person quantity fees that have been excessive, and insufficient employee assistance to assist homeless sufferers, together as Michael. The healthcare personnel had minimal coverage focused on the reality of having assets, and most practices inside the solution of homelessness fitness troubles are no longer adequate.
Breakdown in Monitoring	Overcrowding and prolonged wait times brought about a lag in monitoring Michael’s worsening state of affairs. Alarm fatigue, created through repetitive alarms, prevented the proper detection of his worsening infection. Loss of right monitoring of sufferers, moreover, caused the loss of interventions, resulting in needless amputation.
Prevention Measures	Hospitals want to have formalized interventions for homeless-affected persons. Organizing ER personnel focusing on homelessness care can permit coordination and re-refocusing referrals (Chen et al., 2024). Educating healthcare organizations on trauma-knowledgeable care enhances communication and increases faith and compliance with the treatment protocol. ExtraExtra collaboration with shelters and network organizations can allow greater compliance with care and cut ER prices. Addressing the systemic foundation issues of Michael’s state of affairs can result in superior and fairer treatment of homeless sufferers.
Improving Patient Safety	Reporting and comments: Affected patient safety improvement for people experiencing homelessness, as Michael Carter calls for an extensive chain of intervention. Referral to safety at some unspecified time in the future of standardized discharge plans must be protected similarly to get proper entry to medicine to lower ER readmission and look at care coordination as documented by Figueroa et al. (2020). Schooling of staff on green interventions amongst homeless sufferers and sensitization packages for biases can enhance current-day-affected individual practices as studied with the resource of Bohlen & Shah (2025). In the end, personnel reporting and suggesting solutions to beautify increased over the years, and health center recommendations grounded in coordination with network agencies have become available resources. Hospitals can improve Michael’s protection, lower healthcare expenses, and provide greater equitable care by solving the underlying reasons for ER overcrowding and health disparities. A lively, organized method ensures higher fitness consequences for homeless people, further to the healthcare device.

Root Cause(s) to the issue or sentinel event?

Root Cause(s) / Contributing Factors	HF-C	HF-T	HF-F/S	E	R	B
Failure to provide standardized discharge-making plans for Michael.	X	X
Useless team of workers schooling in social determinants of fitness and trauma-informed care.	X	X	X
ER overcrowding and useless triage strategies.	X	X	X
Inadequate haven referrals should be taken into account, and care coordination should be taken into account.	X	X	X
ER personnel have problems dealing with the homeless sufferers’ trendy needs.	X	X	X
Behind schedule recognition and treatment of emergency instances.	X	X	X	X

Legend:

HF-C = Human Factor – Communication
HF-T = Human Factor – Training
HF-F/S = Human Factor – Fatigue/Scheduling
E = Environment/Equipment
R = Rules/Guidelines/Policies
B = Barriers

Application of Evidence-Based Strategies

Issue

Evidence-Based Strategies

The ED additionally encounters crucial disturbing conditions in the assembly of homeless patients, which encompass Michael equal to scientific necessities as a result of crowding alongside incompetent fashionable walking gadgets and insufficient discharge planning for the sufferers.

Enforcing evidence-based practices like specialized ER social painting frames of people, more potent discharge planning with study-up care, and a similar body of employees training in cultural Competency can lower recidivism in ER visits and enhance the protection of the affected person. They promote higher care coordination, well-timed intervention, and expanded belief amongst Michael and healthcare organizations.

Explain how the strategies could be applied to the safety issues or sentinel events you have identified.

Strategies	Application to Michael’s Case
Specialized emergency room corporations with social employees and case managers can supply direct intervention via help to homeless patients with housing programs, meal assistance, and transportation.	In Michael’s situation, his state of affairs might have been averted from getting worse via a social worker making transportation arrangements to take a look at treatment.
Creating standardized discharge plans with impenetrable discharge referrals and medicinal drug right of entry.	It would have been visible that Michael had a submit-discharge care plan in the vicinity, preventing the infection from worsening.
Trauma-knowledgeable care schooling in health centers and emergency room personnel training.	If ER personnel are skilled in trauma-knowledge care, Michael can also be dealt with extra compassionately and receive clearer discharge instructions, likely resulting in advanced intervention.
Immediate affected individual-employer critiques upon presentation to the ER.	Would boost triage by differentiating between acute and chronic clinical conditions. If this sort of system had been in place, Michael’s viral infection would have been diagnosed as an emergent case and not deprioritized. Consequently, treatment delays would have been avoided.

Safety Improvement Plan

#	Action	E / C /
1	Positioned into effect and sketched uniform discharge techniques with secure haven referral, treatment delivery, and located up-discharge check-up care, making plans to provide coordinated placement up-discharge plans for high-risk patients together with Michael Carter.	C
2	To enhance engagement with homeless patients, including Michael Carter, trauma-informed care and cultural competence should be made obligatory schooling for the ER body of workers.	C
3	Create a dedicated Homeless Care Coordination team in the ER to facilitate verbal exchange and streamline resource provision.	C
4	Institute a real-time reassessment application for homeless sufferers collectively with Michael, with continual contamination to save you from deteriorating infections or emergent situations.	C

Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).

Purpose

To enhance homeless patients’ remedy and save you sentinel activities collectively with now not on time evaluation and amputation of Michael Carter, superior insurance, method, and group of workers development schooling may be adopted. The discharge approach can be advanced by streamlining vulnerable haven referrals and transportation services and examining Americans chronologically. The ER workforce will use evidence-based checklists to ensure complete discharge duties, such as closing care loopholes. ER employees might be required to get trauma-knowledgeable care training, which incorporates identification of the perfect desires of homeless patients, encompassing Michael Carter, implicit bias education, and inclusion of highbrow fitness elements in affected individual care (Bohlen & Shah, 2025). A Homeless Care Coordination organization of ER nurses, case managers, and social personnel can be common, as well as reveal and show that the service has the right of entry to look at high-hazard patients(Harmon & Mariano, 2019). Actual-time triage re-evaluation will upward thrust up if you need to act on time toward sufferers like Michael Carter, whilst there is worsening recognition within the route of ready periods for treatment. A biweekly case assessment will assist in evaluating problems and enhancing coordination strategies, enhancing affected individual effects in elegant and ER readmission commonplace.

Describe the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.

Objective	Timeframe
Enhance care for homeless-affected characters like Michael Carter by improving discharge planning, the framework of people’s schooling, and interdisciplinary communication.	Rolling out dependent discharge strategies in six months.
A decrease in ER readmissions by 20% in 3 and sixty-five days is anticipated.	Within 12 months.
Trauma-knowledgeable care training software application to enhance issuer’s’s self-belief and affect men’s or women’s delight.	Rolled out in six months.
Formation of a Homeless Care Coordination group whose impact could be determined within 3 hundred and sixty-five days.	Implemented in 6 months, with measurable outcomes by 12 months.
Immediately addressing gaps that made it take longer to deal with Michael Carter and preventing similar bad effects.	Immediately addressed through this layout.

Existing Organizational Resources

Resource Need	Availability or Strategy
Secure Haven partnership funding will allow hospitals to go into agreements with community shelters and transitional housing packages.	Presenting robust placements at discharge for patients collectively with Michael and reducing the risk of readmission (Agbata et al., 2021).
Supply price range and close-by investment will be preserved to fund those applications.	ER employees are probably advised on trauma-knowledgeable care to identify implicit bias, check worsening conditions, and provide high-quality care in homeless-affected patient interactions.
Advanced ER nurses, social employees, and case managers’ engagement in discharge-making plans.	Will enhance care coordination with high-risk patients receiving integrated check-ups.
Increase electronic health records (EHR) with automated signs and symptoms for medical deterioration.	To permit real-time reassessment triage, heading off delays in remedy as seen in Michael (Chen et al., 2020).
Management in coverage revision and monitoring compliance.	Needs to implement such changes, ensuring persistent implementation and non-preventive quality improvement (Burke et al., 2022).

References