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

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.

o Who did the problem/event affect, and how?

Mr. Jones Carey, 62, was transferred to Rivera del Medical Institute following a surgical procedure at another hospital. At the time Mr. Carey was in the post-surgical unit, infection control measures were not being performed and he did not know how to identify early signs and symptoms of an infection. Mr. Carey contracted a serious Healthcare-associated Infection (HAI), extending his hospital stay and causing an increased risk of injury to other hospital patients and a decrease in quality of care for other patients. This case illustrates how, if prevention fails or the response to patient injury is inadequate, additional healthcare resources are lost.

1. 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, lack of safety culture, or inadequate leadership support.

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

The development of infection in staff of the hospital was related to several factors, especially individual factors. It is possible that staff have become fatigued from feeling overwhelmed by the volume of work they are responsible for and that this perception of being overwhelmed has led to a lack of compliance with the infection prevention measures, which may have been ignored or implemented less strictly and with less attention to detail. Nantsupawat et al. (2021) pointed out that gaps in infection prevention and control are linked to inadequate staffing and failure to recognize that the patient’s condition is declining. There were several design defects, too. This monitoring system did not provide any protection against staff identifying and responding to early signs of infection. Training and infection control and prevention practices would likely help to strengthen infection prevention within an organization. After a little while, the culture, which sometimes has been disrespectful to compliance with IP&C, may be another reason for the increased disruption to injury to the patient, however, once the systems and processes are in decline.

1. 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.

From the information available, it is clear that there was no regard for infection control after Mr. Carey’s surgery. Infection control policies and practices were probably used, but were not necessarily implemented often. Appointed staff were most likely to have completely ignored the infection control practices. An infection control assessment is very likely not to have been performed, or it was not performed in an unreasonable timeframe. Probably some of the necessary Infection control assessments were not completed. There is likely to be some missing data from Infection control assessment records. Records of monitoring and evaluation of vital signs and Mr. Carey’s post-operative status may not have been completed. No monitoring was done of Infection control. Sartelli et al (2024) state that the Infection control system, standards and policies have likely been breached, and that multiple system failures have likely occurred, but the omissions/violations by staff were isolated and likely manual.

1. Who was involved?:

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

o Supervisors and Managers: Investigate

The nurses, qualified doctors, infection prevention and nursing leadership team members were many of the members of Mr. Carey’s healthcare team. The nursing supervisors, managers, and frontline staff had the closest contact with infection control procedures, as this team was the most involved with monitoring the patient and reporting any significant changes in the patient’s condition. The environment was mostly influenced by the supervisors and managers, while the direction of infection prevention and control was primarily reliant on the staff control and support. No policies existed that had a very clear structure to establish and define accountability, and no support for the ongoing implementation of control in the various shifts. Lack of leadership control and lack of policy reinforcement are directly related to lack of consistency in operational processes and are likely to lead to unnecessary adverse outcomes, according to Cappelli et al. (2024).

1. Was there a breakdown in communication?:

o Interdisciplinary Communication: Assess how well different teams communicated.

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

The poor communication caused the infection to get worse. The clinical issues that developed were not well communicated to the remainder of the health care staff, causing delays in the evaluation of the patient and critical care. There was informal communication at this stage, and critical information to enable a time-sensitive intervention was not available. The staff also failed to communicate to the patient the degree of importance of the need for him to verbally report the worsening infection. Barriers to care coordination and timely interventions to protect the patient will be best removed through consistent communication (Howick et al., 2024). The breakdown of communication rendered the surveillance of infections totally unhelpful and caused additional harm to Mr. Carey’s already poor condition.

1. What were the contributing factors?:

o Physical Environment: Consider facility layout, equipment availability, and workspaces.

o Staffing Levels: Evaluate if staffing was adequate.

2. Training and Competency: Assess staff’s knowledge and skills.

There were many bad conditions, primarily environmental and personnel, which resulted in a negative outcome. Resource constraints caused a shortage of staff to the point where it was not even possible to monitor the patients and adhere to the infection-control standards. Also, standards of infection control may have been overlooked because we have been excessively busy, working outside of normal working hours, and lacking validated competency in infection control and early recognition of infections. If continuous education services and training are limited, staff performance and safety standards are likely to be negatively impacted in a healthcare facility, per Zhang et al. (2024). All these contribute to a lowered situation in the standards of safety to protect the patients from the threat of infection

1. 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.

Policies are the conditions that promote infection. There may not have been clear directives regarding surveillance, escalation procedures, or compliance with procedures for infection control. There was some variation in staff understanding of the policy, and many departments may not have had the most up-to-date infection control guidelines. Policies may be updated infrequently, which may not provide opportunities to present the most current evidence to the practice. Vikan et al. (2023) suggest that organizations that do not regularly review and update their policies will likely have a lack of consistency in implementing safety policies, and the risk of patient injuries that could have been prevented will be greater.

1. 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.

The lack of oversight and monitoring was a major factor in this situation. The first signs of infection were not dealt with in a timely manner to prevent decline. Clinical notes and infection screening per patient were not a catalyst for the appropriate level of care. Formal surveillance systems, in place to alert the clinician to the potential for infection, were not completely used or were not integrated into the system.

1. 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.

In this instance, it demonstrates how important it is to ensure infection prevention is acknowledged at least by all workers, as part of a standard routine, with flexible and innovative quality improvement. Clinical deterioration systems and work to monitor and act on clinical deterioration must be strengthened to stop these occurrences. The organisation should describe the concept of infection prevention, and the consequences of complying with and escalating documentation. This also means leaders provide continued accountability and get staff involved in patient safety initiatives. Connor (2023) said that the most sustainable improvements are those that healthcare organizations establish operational systems that facilitate the regular use of evidence-based practices in all areas of healthcare.

1. How can patient safety be enhanced?:

o Risk Mitigation: Develop strategies to minimize risks.

o Education and Training: Ensure staff are well-trained.

2. Reporting and Feedback: Encourage open reporting and learning from mistakes.

A multi-faceted approach is needed to improve patient safety. Infection-prevention bundles and infection-control-surveillance systems will be enhanced. It is also important to design work systems so there is sufficient time to do patient assessments and infection-control tasks. Staffing ratios are adequate, allowing staff to have less workload, and care is provided of better quality. Regular professional learning and competency assessment by staff will lead to better safety and lower adverse events ( Zhang et. al, 2024). For long-term improvements to be sustained, a reporting culture and open communication about safety and performance are critical. Staff should be encouraged to report concerns to the school regarding infection control and to report near misses or failures in infection control, not to be blamed. The safety reports must be analysed and reviewed to establish a pattern and lessons to be learnt. Katantha et. al (2025) explained that organizations that engage in two-way, open, and continuous communication are associated with the promotion of safety culture and better outcomes for patients. Integrated learning and the continual review and management of risk will enable healthcare organisations to address the threat of further Healthcare-Associated Infections and enhance patient safety and the effectiveness and quality of healthcare services.

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

Unreliable measures for infection prevention

Delay in evaluating symptoms of infection

Insufficient observation of infection and inadequate recording

1

Absence of procedures for infection control and inadequate compliance

ü

ü

ü

2

Insufficient staff training related to control, monitoring of infection, and infection reporting procedures

ü

ü

3

Absence of monitoring, reporting and follow-up control instructions

ü

ü

ü

Timely and reliable infection prevention measures, including delays in the recognition of infection, would not be in place, and an example of a sentinel event would be the occurrence of a Healthcare-Associated Infection (HAI). Therefore, the first step in preventing HAIs caused by a lack of infection prevention is to design interventions to prevent the problem. For instance, each prevention safeguard bundle could feature a pathway for clinicians to support the implementation of safeguard control bundles and safeguard bundles for hand hygiene support and management of healthcare devices for infection prevention. To achieve an adequate infection control safeguard, it is important to have a system safeguard in place that not only ensures ongoing infection prevention surveillance, but also provides clinicians with the necessary tools to determine and identify when there is an infection prevention concern. Studies by Alamer et al. (2022) have demonstrated that the link between infection monitoring with the use of standard precautions for infection prevention leads to reduced rates of infection and the guarantee of the safety and quality of patient care.

For Mr. Jones Carey, an example of a post-operative infection prevention bundle would be the implementation of the entirety of the post-operative procedure with an infection prevention policy, including the conduct of a planned risk assessment of post-operative infection. The use of a planned and/or structured risk assessment would have been earlier and more timely and would have escalated and raised the risk of infection to the post-operative team. If the post-operative team had used electronic integrated infection control and/or infection prevention policies, they would have detected and reacted to abnormal findings in the infection control process and/or automated control or electronic infection control policies. Sartelli et al. (2024) highlighted the positive aspects of early identification of preventable complications and/or avoidable hospitalisation due to the prevention and infection control approach. Improved communication to elevate and/or address the concerns would also promote collaboration among the staff and infection control personnel to elevate and/or address the concerns and assist in the patient care process.

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

Construct a customized, consistent infection prevention bundle and an electronic checklist developed for use with surgical patients

C

2

Implement compulsory infection prevention training and training for the early recognition of infection for all staff

C

3

Implement regular reviews of infection control and documentation practice and infection control and documentation practice

C

The actions noted above aim to further develop practices that control infections and prevent patients from acquiring infections. To accomplish this, a group would be created that would be dedicated to this effort within the first six months. In that period of time, this group would be expected to have developed and started to implement the plan. The plan would be in its infancy as training and simulation would take place, while prevention compliance standards would be set and monitored with regular and scheduled audits (Sartelli et al., 2024). Planned efforts to enhance prevention and control of infections would likely end after the first three years of the plan. At this point, it was thought that everyone would be used to having to comply with prevention rules. Following the initial seven years after the infection prevention standards were established, it was expected that formalised continuation of the work to improve audits and other innovative strategies to maintain the focus on infection prevention in priorities would occur.

The objective of the healthcare safety improvement plan is to lower Healthcare-Associated Infections (HAIs) by promoting the development of infection prevention measures and escalating infection surveillance, and enhancing adherence to policies. In the first quarter, infection prevention bundles and electronic surveillance in the medical-surgical units will be introduced. Staff will have received training on infection prevention by the end of the 6th month and be assessed for compliance by competency assessments. In the following six months, readiness and responsiveness of staff about infection prevention will be measured with Healthcare-Associated Infections, and compliance of staff with infection control measures and timely identification of infection-related complications will be measured. The use of continual education and staff assessments, along with following a set of clinical requirements, can have positive safety outcomes in healthcare environments (Bhati et al., 2023). The assessment of the resultant improvements and the effect will be carried out quarterly..

The safety improvement plan may be implemented using multiple existing resources. The infection prevention and control team will possess a wide range of skills relating to infections, with infection surveillance, infection-associated policies, monitoring compliance, and staff education skills being included. Training and competency workshops may have an infection prevention element to the nursing education. There may be no need for additional learning support. Current electronic health records and information technology can be used to develop examples of documentation templates, surveillance notifications and compliance prompts for infection control. Hibbert et al. (2023) noted that there was a significant difference when the safety programs were integrated into the organizational framework. Support from nursing leadership, patient safety committees, and quality improvement will support the review of audits, policies, and monitoring of improvement activity, and increase confidence about the sustainability of the improvement plan.