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

Root-Cause Analysis and Safety Improvement Plan

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Maria Zavaleta

Organization: School of Nursing and Health Sciences, Capella University

NURS FPX 4035 Assessment 2

Professor Denise Barten

February 12, 2025

Understanding What Happened  

1.     Was it?

Michael Carter, a 45-three hundred and sixty-five days-antique homeless diabetic patient with out-of-control diabetes, was brought to the Emergency Room (ER) with an acute infection of the foot. Owing to ER overcrowding and the triage tool that desired sufferers who no longer required pressing care and immediate care, he was once previously assessed to be in a low-acuity category. He waited more than eight hours earlier than he used to be in the end. Once he was subsequently assessed, his circumstances used to be such that hospitalization, on the aspect of the amputation of his foot, used to be on the list. Michael has made many ER visits due to diabetes complications. However, his pretty hard house times and mobility problems have been such that he couldn’t have his scientific remedy regularly. This report steers easy of continuity of care troubles in triage, remedy, and counseling services that can be to be had to homeless clients and might result in a scarcity of equal prevention of horrible outcomes. Following large triage methods, extraordinary discharge practices, and a better, greater, impenetrable social agency may additionally need to save you from such activities routine, all within the close to future. 

2.     What caused this to happen?

  Michael’s hassle used to be manufactured by a series of institutional, social, and systemic troubles. ER overcrowding, as a reliance on the path due to homeless patients searching for aid for persistent contamination, prompted them to do away with the remedy. Poor people flip to the ER as a source of health care in the first instance on account of problems with preventive care (Vohra and Friends, 2022). The ER personnel, who’ve been underneath immoderate stress via treating strategies of the huge class of sufferers, had to differentiate the persistent and severe ailments of homeless patients. Uncomfortable working situations, the largest dreams of the frame of human beings, and a deficiency in steering about the highbrow and social troubles that accompany homelessness only worsened the condition. Reduced typical overall performance in the tool, such as delays in triage and inadequate coordination amongst social provisions, impacted the effectiveness of the healthcare device. Benevolent elements, i.e., socioeconomics, and which might be extra encompassing, i.e., the financial disaster at the housing scarcity’s side, have moreover made Michael reliant at the ER and worsened a chain of fitness headaches that did not abate (Franco and co-workers, 2021). 

3.     Do you Notice Differences in the Standards or Protocols? 

Most hospitals these days do not file homelessness records based on scientific histories. This outcome is terrible care coordination in addition to the absence of home choices (Garg and Notable, 2021). Michael’s situation is an instance of the method of incomplete files and discharge plans causing fractured fitness care. Those afflicted with the resource of poverty typically no longer revel in the proper of get right of access to the scientific facts of former patients, which means it’s hard for medical practitioners to examine the individual’s evaluation, treatment, and compliance with the recommended medicinal drug. This may cause complications that may be avoided, as well as commonplace hospitalizations. 

4.     What was the Cause? 

ER clinical doctors and nurses, on the side of social people, became part of Michael’s care as an important aspect of his treatment.
The tight rate variety did not leave them with room to provide whole-carrier health facility remedies. Clinic administrators additionally may be quite powerful for guidelines that are counter to homelessness but cannot continually prioritize unique measures (Burke et al., 2022). additionally, homeless advocacy agencies, municipal officials, and health agencies, apart from deferment, structure the health disparities insurance. Multiplied coordination of such sports is essential to accomplishing extra human contact with health providers at the same time as retaining the cost of getting access to the ER as low as possible.

5.     Was there a gap in communication? 

The ER body of individuals’ inability to organize themselves, the Social people ER group of health workers, and the discharge planners resulted in dispersed care. A maximum of homeless patients experience difficulties in acquiring fitness literacy and, in fact, have difficulties understanding commands for discharge (Lateckova and al. 2025). Michael was discharged previously without an adequately defined study-up method, and this resulted in severe exacerbation of clinical situations. The collapse of communications between some of the medical examiners and the local government resulted in the collapse of opportunities for medical treatment and a lack of sufficient support after discharge. Bad patients usually have problems with literacy, as do intellectual contamination and tension, and a lack of trust in the healthcare professional that prevents adhering to scientific advice.

6.     What was the Cause of the issue? :

ER overcrowding can bring about unstable medical conditions alongside an extended wait and a low quality of hospital therapy like in Michael’s case. Michael. Understaffing causes delays in addition to an upward trend in the amount of burnout among clinical experts and strains the healthcare system, as stated by Lateckova and. al. (2025). Inside, the emergency hospitals were full of patients and no longer used as a venue to go to and with few facilities to cater to the needs of homeless humans like Michael, medical necessities together with showers, and short resting regions.

7.     Training and Competency:

Shortages of employees induced emergency treatment in addition to substandard care of the social needs of homeless sufferers which brought on delays in treatment of clinical conditions and substandard up-discharge treatment for discharged patients from the hospital. Most fitness professionals no longer realize ways to cope with the dreams of homeless sufferers, major to severe inequalities, and substandard hospital treatment.

8.     Do the Rules and Regulations of the Company Play an Important Role? 

Most hospitals fail to stick to the ideal strategies in coping with the scientific desires of homeless sufferers, together with Michael, and this is the reason for inconsistent care. Loss of grasp concerning the available close-by fitness assets may also save the body of workers from linking sufferers with indispensable health belongings. It creates gaps in healthcare and may reason repeated ER visits, as noted with the aid of Lateckova and her group. (2025). there may be a need for rethinking the strategies for responding to emergencies designed in acute care environments that no longer meet the wishes of rules as they are now not capable of dealing with scientific troubles, which might not be unusual amongst those dwelling in shelters. This brought about a loss of remedy preferences and an inequitable distribution of available resources. Rules for remedy-making plans to discharge and social services referrals had been not effective in implementation owing to the dearth of sufficient belongings for the frame of people or the exceptional kind of patients alongside the terrible help from the personnel to homeless patients on the side of Michael. Fitness care employees showed terrible comprehension of policy in terms of the services and practices of indoor organizations to address issues related to homelessness and health was not well-described.

9.     Was there a glitch in surveillance or monitoring? :

Overcrowding and prolonged ready time led to the failure to song Michael’s contamination, which used to worsen. Exhaustion amongst the body of personnel contributors, owing to the several notifications caused an untimely estimation of contamination severity. Overlook approximately in the affected man or woman’s remedy also caused delayed remedy and in the long run, a fatal Amputation.

10.  What Lessons can we Take to Prevent Repetition?

Hospitals must create systematic techniques to enhance access for homeless patients. The repute quo of ER groups with knowledge in treating homelessness may additionally need to improve coordination and accelerate referrals (fowl and Friends span> 2024). coaching fitness care employees in imparting trauma-informed care improve conversation and improves compliance and faith in remedy tactics. Enhancing coordination with shelters and groups can doubtlessly enhance look-at-home care and reduce ER dependency. The systemic reasons for Michael’s experience can be addressed to provide more honest and equitable offerings to homeless patients. Preserving the safety of homeless patients like Michael Carter entails various interventions.

11.  How can the Security of Patients be Enhanced? :

The habitual discharge software program ought to consist of shelter referrals and entry to medications to lessen ER admissions and monitor follow-up medical visits, as proposed by Figueroa and associates. (2020). The worker training on the most powerful techniques of handling homeless patients and prejudice attention education can enhance the regular practices of the patients in step with Bohlen & Shah (2025). Furthermore, the chance of the capability of the personnel to provide their reviews and say about their enjoy and how they are able to make topics higher can be a non-prevent improvement, considering health facility policies which can be steady with nearby organizations can improve the degree of assets which are available.

12.  Reporting and Feedback:

By addressing the number one reasons why ER sufferers are whole and closing healthcare gaps that hospital employees come upon, healthcare is probably made more secure for Michael, much less expensive, and even more effective and equitable. Effective and proactive efforts provide better fitness consequences for homeless sufferers and for the fitness care tool as a whole.

The primary Cause(s) for the issue or event that is sentinel-related?

HF-C = Human Factor-communication HF-T = Human Factor-training HF-F/S = Human Factor-fatigue/scheduling

E= environment/equipment R= rules/policies/procedures B=barriers

Application of Evidence-Based Strategies

Select the best way to tackle security issues or the sentinel event.

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

ED faces a whole lot of demanding conditions in terms of providing medical care to homeless sufferers like Michael due to the congested putting, absence of appropriate running strategies, and lack of techniques to permit the patients to be discharged as in step with Paudyal and co-workers. (2022) Homeless sufferers represent a first-rate burden to the health center resources as they tend to rely upon emergency departments to acquire their primary clinical fitness care. Michael’s readmission rate is still high because ER employees, in addition to the health care community body of employees and social employees, no longer coordinate his care correctly. Extremely good healthcare interactions are defeated by the fact that healthcare people are prejudiced and absent proper training to offer trauma-knowledgeable care. It halts affected character-corporation communication as conceived with the resource of Bohlen and Shah (2025). software of modern-day measures, including specialized ER social artwork staff, discharge making plans, and tracking and improving the personnel cultural competence training will reduce ER usage and enhance protection for patients. It will yield extra green healthcare coordination, timely interventions, and a better degree of self-guarantee among Michael and healthcare groups.

Discuss how these strategies can be applied to security issues or sentinel scenarios you’ve noticed.

Using methods grounded mostly on clinical research solves the issue of safety that Michael Carter’s story widely demonstrates and enhances the livelihood of those who live in poverty. A specialization of emergency rooms, which can be staffed via Social personnel and case managers, might be capable of assisting homeless people in the process of finishing requests for food or housing assistance, and additionally transportation (Crone and co. The 12 months 2022 is the date to begin.). In Michael’s situation, there is a risk that the social worker may also want to arrange transportation for his next remedy and halt his fitness from deteriorating. In addition, creating expansive discharge plans with prescriptions further to recommendations to shelters should guarantee Michael had a planned post-discharge form of treatment, which can reduce the opportunity for bacterial contamination to develop into more serious conditions (Figueroa and Co. within the year 2020).

Putting trauma-informed training into educational programs for hospital emergency room staff will reduce the gaps in the treatment of homeless patients (Bohlen as well as Shah, 2025). The practice creates trust between fitness professionals and patients, increasing their engagement in treatment methods and adherence to comply with treatment. If ER staff members were aware of treatments that can be trauma-based, Michael could have received more specific discharge recommendations along with empathetic care and likely sooner treatment. In addition, being able to provide short tests with the patient’s employer all at once after ER arrival enables the distinction between clinical emergencies and chronic infection (Paudyal and colleagues, 2022 ). Had this method been immediately placed in position, Michael’s drastic pollution could have been diagnosed as an urgent issue in proximity to being deemed irrelevant, which could have prevented a delay in treatment.

Partnerships with neighborhood agencies and coverage makers may increase access to the sources desired for publish-discharge care, which can result in a reduction in healthcare prices and further improve long-term period fitness outcomes for individuals who are homeless. Through the incorporation of the one top strategy, hospitals can potentially develop a green and empathetic approach to healthcare that is focused on the protection of sufferers at the same time as considering the fitness elements that have an effect on society (Paudyal and Co. 2022 ). Repairing the problems that Michael’s criticisms have revealed through those methods can lead to additional access to healthcare for everyone, prevent unfavorable outcomes, and limit the number of emergency centers that could be overcrowded.

Safety Improvement Plan

Notify us of any changes that are required in the near future to prevent repeating.

E is for Eliminate (i.e., that piece of equipment gets removed and repaired or replaced. )

C = control (i.e., additional step/warning is added, or staff is educated/re-educated)

A is for Accept (i.e. discussion informally or informally about “don’t let it happen again” or “pay better attention” but nothing else can be changed, so it is accepted that there will be a chance)

Safety Improvement Plan

It is a wonderful way to adorn healthcare for homeless individuals as well as to prevent sendinginel activities like Michael Carter’s takeover of surgical procedures and amputations. New procedures, guidelines, and methods to make professionals more beautiful are in the vicinity. The normal discharge system ensures certain patients have cited shelters, are helped in transportation, and booked for the next visit. ER staff will adhere to the recommendations for undertaking significant discharge procedures, thereby eliminating the risk of coordination delays. Education in trauma-aware medical care is presently mandatory for ER staff. The attention may be on the particular needs of individuals who are homeless, such as Michael Carter, addressing implicit discrimination and the cognitive health component in interactions with victims (Bohlen and Shah 2025 ). Additionally, the Homeless Care Coordinating institution is to be set up consisting of ER social, medical specialists, nurses, and case managers who will monitor the method of the availability of services and screen individuals who are at risk (Harmon Mariano, Harding, and Harding 2019). Real-time triage assessment is planned to ensure that the likes of Michael Carter receive access to timely intervention during the event in case their case deteriorates on the same timeline as they are looking forward to fixing. Every week, the review of the case allows us to see what is required and helps expand the method for coordination. This could enhance the daily outcomes of affected persons and reduce ER admissions.

Give a clear sketch of the goals or goals you wish to achieve from these steps as well as a rough timeline of development and implementation procedure to execute the plan.

The aim of the program is to decorate the affected person and take care of patients in need like Michael Carter via higher discharge instances, education team of workers, and communication throughout disciplines. NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan the setting and execution of clear discharge protocols within 6 months, the aim is to gain a reduction in ER admissions by 20%% in three hundred and sixty-five days. Furthermore, the trauma-knowledgeable health schooling software may be initiated within 6 months to decorate faith in affected character remedy further to improve healthcare corporation pride. Thanks to improved coordination of care, a Homeless Care Coordination group could be created within 6 months. The impact can be measured within three hundred and sixty-five days to guarantee that budgets are allotted effectively. This application solves the problems that triggered Michael Carter’s put-off in his treatment. It guarantees that any adverse consequences like those of Michael Carter might not arise in destiny.

Existing Organizational Resources

Learn about the resources that might need to be procured to implement your safety strategy. Examine what existing resources can be used to enhance the safety strategy. +

Hospitals should accumulate and employ the greatest amount of needed items required to deal with individuals who are homeless, and also avoid sending new-related events such as the delayed treatment of Michael Carter and subsequent amputation. The shelter funding agreement enables hospitals to agree with shelters in neighboring areas and shelter facilities that provide intervening time for housing. It is of paramount importance to ensure that patients with disabilities, including Michael, have solid accommodation upon discharge and reduce the chance of rehospitalization (Agbata and Co. 2021). 

Local support, in addition to grants, ensures that those efforts will be maintained. ER staff will be trained in trauma-informed clinical to learn about unconscious bias as well as become privy to any health concerns and learn the most effective methods for dealing with homeless human beings that could assist in ensuring that Michael’s deteriorating condition is addressed more quickly. Furthermore, the empowerment of ER social workers and nurses, as well as ER nurses at the bedside of times managers’ role at some point in the process of discharge, will improve care coordination and ensure patients in need receive the appropriate remedy. Enhancing virtual health information (EHR) with computerized indicators of fitness issues with real-time alerts will allow for further exploration of triage to prevent delays, such as individuals who Michael previously once faced (Chen and co. in the year 2020). ).>> The support of the top management in carrying out coverage adjustments in a similar manner to ensure compliance will ensure ongoing execution and continuous growth at the pinnacle of care (Burke and Co. 2022).

References

Agbata, E., Hung, J., Magwood, O., Moledina, A., Pottie, ok., Saad, A., & Thavorn, okay. (2021). A complete evaluation of the most crucial sports to improve the wellness and health of people with lived experiences of homelessness. Campbell Systematic critiques, 17(two). https://doi.org/10.1002/cl2.1154

Bird, k. T.., Brady, L. A., prepare dinner, E. G., Crandall, A., Friedrichs, H., Hanson, C. L., Novilla, M. L. B., & Obalana, O. (2024). U.S. doctors’ schooling and experience providing trauma-knowledgeable hospital therapy within the clinical setting. Global magazine of Environmental Research and Public Health, 21(2). https://doi.org/10.3390/ijerph21020232

Bohlen, J. & Shah, H. S. (2025). Implicit Bias. In-Stat Pearls. Stat Pearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK589697/

Burke, N. J., Fleming, M. D., Hanssmann, C., Rasidjan, M. P., Shim, J. ok., Thompson-Lastad, A., Van Natta, M., & Yen, I. H. (2022). “Housing is fitness care” of treating homelessness in safe internet hospitals. medical Anthropology Quarterly, 36(1), forty four-sixty three. https://doi.org/10.1111/maq.12665

Chen, M., Padman, R., & Tan, X. (2020). Fitness-associated social determinants in digital fitness information, and their results on chance evaluation and assessment in a scientific take a Look at. magazine of the Yankee Medical Informatics Association: JAMIA, 27(11), 1764-1773. https://doi.org/10.1093/jamia/ocaa143. NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan.

Crone, B., Metraux, S., & Sbrocco, T. (2022). Access to fitness services for homeless veterans: health gets entry to problems that homeless African American Veterans face. mag of Racial and Ethnic health Disparities, 9(5), 1828-1844. https://doi.org/10.1007/s40615-021-01119-z

Figueroa, J. F., Hasegawa., Miyawaki, A., & Tsugawa, Y. (2020). health center readmissions and emergency department visits of homeless sufferers admitted to hospitals that serve homeless patients in the U.S. Take a look at the remark. magazine of preferred internal medicine, 35(nine), 2560-2568. https://doi.org/10.1007/s11606-020-06029-0

Franco, A., Meldrum, J., & Ngaruiya, C. (2021). Figuring out the desires of homeless humans inside the emergency department through the use of participation-primarily based studies inside the network. BioMed Central BMC fitness services research, 21(1), 428. https://doi.org/10.1186/s12913-021-06426-z

Garg, R., Kreuter, M. W., McQueen, A., & Thompson, T. (2021). The social determinants of the fitness region: proof of challenges and possibilities in public fitness. Annual assessment of Public fitness, forty-two, 329-344. https://doi.org/10.1146/annurev-publhealth-090419-102204

Harmon, M. J. & Mariano, M. A. (2019). Living libraries: integration of nurses into the interprofessional fitness take care of the homeless crew. Public Fitness Nursing (Boston, Mass. ), 36(two), 172-177. https://doi.org/10.1111/phn.12561

Lateckova, B., Potluka, O., & Simon, M. (2025). The usage of healthcare and fitness offerings by using way of the homeless human beings: An assessment research of joint social work and fitness care. Global mag of Nursing Studies, 161. https://doi.org/10.1016/j.ijnurstu.2024.104929

Paudyal, V., & price, M. J., & Vohra, N. (2022). Homelessness and the function of emergency departments as resources of health care: a systematic evaluation. worldwide journal of Emergency medicine, 15(1), 32. https://doi.org/10.1186/s12245-022-00435-3

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