For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your

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?

A patient with heart failure received ED discharge without proper understanding of their diagnosis. They also never had complete knowledge about medications or self-care. Lack of understanding from the patient resulted in readmission because their symptoms grew worse. It also caused lower satisfaction for patients. The event produced preventable complications in the patient together with emotional distress for providers and extra costs alongside reputation damage for the hospital facility.

At the ED the patient arrived because of heart failure's sudden onset symptoms. The healthcare staff discharged the stabilized patient while providing instructions about both self-care practices and medication requirements. The acute nature of the ED made the discharge process brief thus preventing the patient from comprehending all information. Insufficient patient understanding of prescribed treatment plan led to non-adherence. This caused their healthcare condition to worsen.

1. Why did it happen?:

   • Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.

   • System Factors: Examine workflow processes, equipment failures, and environmental factors.

   • Organizational Culture: Assess if there are cultural issues, lack of safety culture, or inadequate leadership support.

   • Society/Culture: What role might cultural assumptions or backgrounds play?

Several human and system and organizational elements combined to result in the event. The inadequate patient education process along with failed communication between healthcare staff. A combination of tired staff members together with insufficient staffing numbers led to hurried discharge procedures. The high-pressure environment restricted nurses from devoting lengthy periods to educate patients properly. The disorderly patient environment combined with insufficient education areas made it more challenging to deliver quality education to patients. The absence of an effective patient safety culture which prioritized education and follow-up combined with unapproachable discharge education guidelines constituted the organizational factors.

Health literacy of the patient remained low because of cultural background which prevented them from grasping complex medical information. Delivery of adequate patient education requires assessment of cultural background for effective outcomes.

1. Was there a deviation from protocols or standards?:

   • Procedures and Policies: Determine if established protocols were followed or if there were deviations.

   • Were there any steps that were not taken or did not happen as intended?

   • Documentation: Review medical records, nursing notes, and other relevant documentation.

The healthcare staff failed to follow the standard operating procedures education guidelines for patient discharge instructions. The discharge procedure happened quickly while the patient received insufficient time to get answers or better comprehend the instructions provided. Inadequate documentation regarding the discharge education showed that the patient’s understanding of received instructions lacked proper documentation.

1. Who was involved?:

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

   • Supervisors and Managers: Investigate

The patient together with nurses physicians and pharmacists formed the group of direct participants during this event. The supervisory team along with management had responsibilities to maintain nurse improvements for patient safety rules and standards.

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.

The event resulted in substantial failures of provider-to-provider communication and patient-provider communication. Different medical staff delivered different standards of information to the patient which caused inconsistent communication. Patient-provider communication failed because the patient received insufficient information along with a lack understanding regarding their care plan.

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.

The ED's disorganized and open physical space prevented patients from receiving private education. Rushed clinical interactions occurred because staff members were not able to provide adequate care. A lack of adequate training and competency became a problem because employees failed to demonstrate proper use of patient education methods that included the teach-back technique.

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 occurrences were influenced by established organizational policies together with current procedures. The established protocols for educating patients about discharge requirements did not receive enough policy compliance throughout the healthcare organization. The accessibility issues with policies together with their unclear wording compounded the irregularity in patient education.

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.

The initial ED staff successfully monitored all vital signs of the patient throughout their first visit. A failure to check how well the patient comprehended discharge instructions resulted in an adverse patient outcome.

1. What can be learned to prevent recurrence?:

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

   • Quality Improvement: Consider implementing preventive measures.

Standardized educational approaches for patients and better team communication must become part of the system to prevent such occurrences. Training specifications pointed toward the necessity of implementing evidence-based patient education approaches particularly through the teach-back method usage. The quality improvement process should include developing clear visual materials and easy-to-understand content to improve patient comprehension.

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.

Risk mitigation strategies that combine teach-back methods and visual aids help boost the safety level of patients by enhancing their comprehension. Strengthening staff abilities in patient communication along with education techniques needs proper training. Healthcare facilities need to create an environment that promotes safety by welcoming open error reporting for continual advancement.

A communication failure involving medical staff members and their patient served as the main source of this critical adverse event. The problems were made worse because staff underutilized evidence-based educational methods for patients especially the teach-back technique while running non-uniform discharge education protocols. Three main factors that led to the incident were the pressured Emergency Department conditions alongside insufficient staffing and nontransparent policies that were hard to grasp.

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

Communication breakdown between the providers and patients.

The healthcare providers did not use enough evidence-based approaches.

There were inconsistent enforcement measures on the discharge enforcement.

There was a high ratio between patients and sfall members in the healthcare environment. This led to Chaos.

There was poor staff traning on teach-back approaches.

The policies were unclear and not accessible.

Healthcare professionals should implement three evidence-based practices which combine teach-back methods with visual aids and simplified materials together with standardized discharge procedures. Research indicates that teach-back serves as a proven technique to verify patient comprehension and enhance their commitment to medical plans (Felker et al., 2020). Studies prove that visual aids along with simplified materials help patients understand better especially when their health literacy levels are low (World Health Organization, 2021). Standardized discharge procedures improve patient survival rates and lower hospital admission rates thanks to their function in maintaining clear communication (Singh, 2024).

Applied in the emergency department medical professionals should receive teach-back training and protocols for visual explanations of conditions such as heart failure must be developed with a procedure in place to verify the delivery of critical discharge instructions. Healthcare providers who implement these operational practices will boost patient comprehension together with lower adverse event frequencies in their daily activities

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

Education regarding teach-back methodology must be delivered to all ED staff while continuing their education. The staff needs proper training in teach-back methods which will help them verify patient knowledge levels during the discharge process.

C

Standardized visual aids together with simplified discharge materials will be developed for distribution to patients. A set of educational materials will improve patients' grasp of their care plan directions especially for those who have limited skills in health understanding.

C

Healthcare facilities need to develop standard discharge education policies which must remain easily reachable to staff members. Clear policies create standardized patient education while reducing chances of poor communication.

C

The standardized discharge checklist combined with teach-back protocol will function as new processes which guarantee patients receive essential information. Healthcare organizations will create policies that require all discharge educators to utilize teach-back methodology and visual educational materials. The staff of ED will receive training about evidence-based patient communication methods during quarterly professional development sessions to achieve proficiency in these methods.

The objective focuses on decreasing patient readmissions because of misinterpretation by 50% throughout one year. The goal toward achieving this objective follows the following time frame:

Staff training regarding the use of teach-back method and creation of visual aids takes place within Months 1-2.

The ED will conduct a standardized discharge process deployment during months 3 to 4.

The research team will assess pilot program performance and perform modifications between months 5 and 6.

The standardized discharge process reaches complete implementation during months 7 through 12 while continuing to monitor its performance to maintain continuous improvement.

Additional funding should be allocated to train staff properly and produce visual aids as well as amend policies to achieve successful plan execution. The hospital IT systems currently in use can be used to generate digital versions of visual materials which will integrate with electronic health record systems. Successful distribution of developed resources requires joint efforts between health educators and information technology experts.