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

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan Student Name Capella University NURS FPX 4035   Instructor Name Submission Date   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,