For this assessment, you will develop an 8–14 slide PowerPoint presentation with thorough speaker's notes designed for a hypothetical in-service session related to the improvement plan you developed i

Root-Cause Analysis and Safety Improvement Plan

Alyssa LaPierre
Capella University
NURS-FPX4035
Dr. Maxine Jeffery
June 2025

Root-Cause Analysis and Safety Improvement Plan

Understanding What Happened

An incident requiring investigation happened when there was a problem in communicating during a handover of a patient, which resulted in a patient receiving incorrect medication. The incident affected the patient with regard to receiving the wrong medicine and it negatively affected the staff, since it was preventable. It was caused when nursing staff did not get enough or inaccurate information from one another. Some of the reasons for this were, talking during handoffs instead of clearly writing things down, avoidable distractions in the process, and a lack of enough staff.

Root Cause Analysis

Ineffective communication about patients’ status from one doctor to another is the main reason behind this sentinel event. The biggest problem was communication among staff, human factor-communication, and this was caused by fatigue and scheduling, lack of training, and unclear protocols. Nurses said they experience too many interruptions and don’t always have enough time to discuss all the details with doctors. Because documentation in the electronic health record (EHR) was not always the same, things were misunderstood, and important information were missed. Each shift or department used its own way to hand over patients because the organization did not have handoff procedure. As stated by The Joint Commission (2022), miscommunications between shifts are a leading reason for sentinel events and a constant problem for safe patient care.

Application of Evidence-Based Strategies

Evidence-based research points out that using systematic communication tools guarantees everyone gets the information they need. Using SBAR (Situation, Background, Assessment, Recommendation) and I-PASS (Illness severity, Patient summary, Action list, Situational awareness, and Synthesis by receiver) has been proven to help decrease the number of medical errors by an average of 30% (Starmer et al., 2015). If you use these tools, it will make sure all important patient data is transmitted correctly. Time and places devoted to quiet handoffs in caretaking can help hold 40% extra information in the mind (Cohen et al., 2018). Simulation training is valuable for teams since it focuses on better communication and helps enforce the best methods for passing duties from one healthcare worker to another (Riesenberg et al., 2020).

Safety Improvement Plan

Several important measures have been suggested to stop it from happening again. First, using the SBAR framework everywhere will make sure everyone handoffs information in the same way. Next, members of staff will be required to participate in simulation exercises for improving their use of structured communication tools. In addition, places where staff conduct patient handoffs will be decided to avoid working when others are present. EHR handoff documentation will be made mandatory with the use of a standardized form introduced by the policy change.

The main purposes of this plan are to keep the handing-over of care information more complete and clearer, minimize errors when giving medication, and help patients achieve better results. The update will take three months, starting with testing pilots in units such as the ICU and ED and then being used everywhere in the hospital.

Existing Organizational Resources

There are several resources in place that will back the success of this plan. The existing EHR used at the hospital can have the SBAR and I-PASS templates added to them. The education department will set up classes and exercises for staff. When nurse managers and unit supervisors join in, it will help everyone follow the rules and demonstrate the right conduct. The team will keep an eye on how successfully efforts are carried out and evaluate progress in handing off information safely and preventing adverse incidents. Furthermore, including patients and their families in handoffs allows for another check and promotes open and teamwork-based culture among the health care team.

References

Cohen, M. D., Hilligoss, P. B., & Kajdacsy-Balla Amaral, A. C. (2018). A handoff is not a telegram: An understanding of the patient is co-constructed. BMJ Quality & Safety, 27(3), 223–231. https://doi.org/10.1136/bmjqs-2017-006696

Riesenberg, L. A., Leitzsch, J., & Cunningham, J. M. (2020). Nursing handoffs: A systematic review of the literature. Journal of Nursing Care Quality, 35(1), 1–7. https://doi.org/10.1097/NCQ.0000000000000423

Starmer, A. J., Landrigan, C. P., & I-PASS Study Group. (2015). Changes in medical errors after implementation of a handoff program. The New England Journal of Medicine, 372(5), 490–491. https://doi.org/10.1056/NEJMc1414788

The Joint Commission. (2022). Sentinel Event Alert 58: Inadequate handoff communication. https://www.jointcommission.org