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

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

Root-Cause Analysis and Safety Improvement Plan

FPX 4035

Capella University

Prof

Date

Root-Cause Analysis and Safety Improvement Plan

Category	Details
Appreciation: What had happened	Michael Carter, a forty-one-year-old diabetic homeless man or woman with poorly controlled diabetes, presented to the emergency department (ED) with excessive foot contamination. Because of ED overcrowding and an ED triage procedure that targeted nonemergent patients, he was once as soon as he decided to be low acuity. He waited more than eight hours to be visible. Via then, his infection had stepped forward, and he needed to be admitted and a characteristic part of the foot amputated. Michael had already been to the ER several times with headaches from diabetes, but his homelessness and the absence of transportation meant that following up was not feasible. His case brings to light systemic issues of triage, continuity of care, and dealing with people experiencing homelessness, essential to avoid avoidable destructive results. Applying specialized triage protocols, superior discharge-making plans, and exceptional social services integration should have prevented such occurrences.
Why did it rise?	Michael’s adverse final results used to be the capitulation cease result of a combination of human, systemic, organizational, and societal factors. Crowding within the ER, an element fueled by the method of homeless patients dealing with continual situations, introduced treatment delays. Homeless sufferers use the ER as an aspect of primary access to hospital treatment, because preventive care is scarce (Vohra et al., 2022). The ER employees, whose workload harassed them, could not differentiate between persistent and acute infections in homeless sufferers. Terrible running conditions, immoderate caseloads, and inadequate training inside the social dynamics of homelessness contributed to one’s troubles. Device inefficiencies, on the side of behind-schedule triage and awful social company coordination, restrained effective care. Massive socioeconomic instances, which encompass economic lack of self-assurance and homelessness, moreover, moreovmoreoverel’s usage of the ER, create a cycle of horrible health outcomes (Franco et al., 2021).
Was there an infringement of fashion or protocol?	No standardized homeless patient tips are available in hospitals, and due to this, care remains non-standardized. Maximum does not report homelessness within the scientific report, resulting in discontinuities in care coordination and the possibility of lost follow-up (Garg et al., 2021). Michael’s situation is a traditional instance of strategies with disorganized discharge planning and documentation resulting in fragmented care. Homeless patients have not been admitted to previous scientific studies, so carriers can not display diagnoses, treatments, and remedy compliance. Such departures from favored workouts result in vain complications and excessive hospitalization.
Who used to be concerned?	ER nurses, medical doctors, and social workers had been a part of Michael’s remedy; however, they were shortchanged by the lack of a price range for massive intervention. Health center administrators make suggestions that affect homeless care; however, they do not constantly make formal interventions an immoderate precedence (Burke et al., 2022). Homeless advocacy organizations, city governments, and public fitness businesses structure suggestions to close healthcare gaps. Elevated coordination amongst stakeholders is fundamental to enlarging proper entry to care and reducing preventable ER visits.
Was there once a communication breakdown?	Inadequate coordination among the ER body of employees, discharge planners, and social workers contributed to disjointed care. Patients who are homeless are broadly stricken by horrific health literacy, and therefore, it becomes difficult for them to comprehend commands for discharge (overdue. ková et al., 2025). Michael used to be discharged as quickly as possible despite the planned examination diagram, which led to deteriorating health results. A verbal exchange between the various healthcare groups and the network properly led to misplaced care possibilities and insufficient submit-discharge help. Homeless patients, moreover, have literacy issues, highbrow infection, and distrust of the clinical device, which, in addition, prevent care compliance.
What had been the contributing elements?	Training and Competency: In Michael’s scenario, R overcrowding creates volatile environments, longer wait times, and terrible patient care. Inadequate staffing also creates delays and enhances organizational burnout, in addition to getting the healthcare device, as described by the beneficial resource of Lateková et al. (2025). The bodily centers of emergency rooms have been overcrowded with a lack of consultation rooms and insufficient provision for homeless sufferers, collectively with Michael’s hygiene needs, including showers and quick resting areas. The employee shortage introduced approximately rushed emergency treatment and inadequate assistance for homeless sufferers’ social needs, resulting in no longer on-time hospital treatment and insufficient follow-up care at clinic discharge. Numerous healthcare companies also lack proper schooling to cope with the homeless complicated desires, leading to disparities and poor health outcomes.
Were organizational recommendations or techniques accountable?	Most hospitals lack definitive guidelines to address the fitness needs of homeless patients, collectively with Michael, resulting in patchy care. The personnel recognize very little about the community property, and the affected person’s referral to crucial services is difficult. This is a cause of healthcare inequalities and a predictable cause of recurrent ER use, as researched by Lateková et al. (2025). The identical antique emergency care hints that superior acute settings prompted traumatic situations in insurance compliance because they did not efficiently cope with homeless sufferers’ continual issues, thereby generating disregarded care opportunities and the unequal allocation of resources. Discharge planning rules and social provider referrals have not been accomplished as the ideal method owing to insufficient employee resources, excessively affected character volumes, and inadequate help from the right body of human beings to help homeless sufferers, including Michael. Coverage focus was once as quick as negligible among healthcare organizations. Due to the t,ruDue, there has been an appropriate clarification of present community sources and Excel practices in times of homelessness.
Was it as quickly as there was a tracking or surveillance breakdown?	Overcrowding and, in addition, wait times added to a breakdown in monitoring Michael’s state of affairs because it was once again deteriorating—alarm fatigue from repeated alarms brought about not on-time detection of his developing contamination. Patient tracking breakdowns moreover led to delays in appearing nicely timed interventions, in the end, primary to a preventable amputation.
How can recurrence be prevented?	Prepared health facility interventions are quintessential to beautify care for homeless-affected persons. ER organizations focusing on homelessness care can improve coordination and make referrals much less challenging (Chen et al., 2024). Trauma-informed care training amongst the healthcare body of human beings complements communication, establishes trust, and improves treatment plan adherence. Growing collaboration with network programs and shelters can provide access to care and decrease ER reliance. Treating the systemic etiology of Michael’s case can bring about stepping forward and further equitable, homeless-affected character care.
How is it affected by men’s or women’s protection superiors?	Reporting and feedback: Improving the individual protection of affected homeless sufferers, which includes Michael Carter, requires a whole continuum of interventions. Referral to shelters wants to be blanketed in planned discharges collectively with medicinal drugs, to get the right of admission to lower ER readmission and facilitate adequate look aftercare coordination as documented by the method of Figueroa et al. (2020). Sensitivity to biased schooling programs, workforce education on first-class remedies for homeless sufferers, and grievance conduct tracking programs can beautify fashionable patient practices, as studied by Bohlen and Shah (2025). In the long run, empowering employees to file problems and recommend solutions guarantees ongoing development. At the same time, suggestions within the clinic for selling cooperation with community organizations can maximize assets. By addressing the underlying causes of ER overfilling and fitness disparities, hospitals improve Michael’s safety, lower healthcare expenses, and deliver extra equitable care. A properly prepared, proactive machine can offer advanced fitness outcomes for homeless patients and a more match-preferred fitness gadget.
What is the root purpose(s) for the trouble or sentinel event?	N/A

Root Cause(s) to the issue or sentinel event?

Explore NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation for more information.

Contributing factors – excellent reason(s) that made a situation flip out a great deal less than the most suitable	HFC	HF T	HF	F/S	E	R	B
Failure to have standardized discharge planning for Michael.	1
ER overcrowding and vain triage tactics.	X
Insufficient secure haven referrals and test-up care coordination.	X	X	2
ER’s body of personnel is not capable of dealing with the complicated dreams of homeless sufferers.	X	X	X	3
Now, there is no on-time identification and treatment of emergent times.	X	X

Legend:

• HFC = Human factor communication
• HF T = Human factor training
• HF = Human factor fatigue/scheduling
• F/S = Environment/system
• E = Environment/system

Application of Evidence-Based Strategies

• Identify the best evidence-based practice strategies to address the safety issue or sentinel event.

Aspect	Details
Problem Identified	The ED is appreciably disabled from providing identical medical care to homeless patients, alongside Michael, as a result of overcrowding that is dominated by a lack of proper stylish strolling techniques and inadequate discharge planning for patients.

• Explain how the strategies could be applied to the safety issues or sentinel events you have identified.

Aspect	Details
Proposed Solution	Introducing specialized emergency department companies comprising case managers and social workers with the functionality to provide postponed interventions by helping homeless patients with requests for housing, food stamps, and transportation (Crone et al., 2022).

Safety Improvement Plan

• List any future actions needed to prevent recurrence.

Step	Action	Root Cause/Contributing Problem	E/C/A
1	Put into effect and located into impact standardized discharge techniques that include shelter referrals, getting entry to medication, and finding-discharge follow-up care coordination to offer installation-based discharge plans for high-risk patients alongside Michael Carter.	E	C
2
3
4

• Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).

Action/Strategy	Description	Expected Outcome	Timeline for Implementation
Homeless Care Coordination Group	A team comprising ER nurses, social workers, and case managers to coordinate access to resources and follow-ups	Improved access to services, reduced patient barriers	3-4 months
Real-time re-triage calls	Ongoing calls to re-triage and address patient needs promptly	Timely responses to patients, especially high-risk ones	Ongoing (with weekly reviews)
Weekly reviews of care coordination	Review of care coordination efforts to identify barriers and adjust strategies	Enhanced patient outcomes and reduced ER readmissions	Weekly (Ongoing)

• Describe the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.

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

Here is your provided content formatted in a table, with no changes made to the content:

Item	Details
ER readmissions reduction	By developing and enforcing primarily based discharge protocols in six months, ER readmissions are expected to drop 20% in three hundred and sixty-five days.
Trauma-informed care training	Trauma-knowledgeable care schooling software may be positioned into an exercise in six months to improve the company’s self-guarantee and enhance employee coordination.
Homeless Care Coordination organization	A Homeless Care Coordination organization can be installed within six months, and its normal typical performance might be evaluated after three hundred and sixty-five days to show how efficiently property has been allocated.
Strategy goal	The method is going out of its way to exclude the loopholes introduced by Michael Carter’s not-on-time remedy and notice that such terrible impacts no longer push up inside destiny.
Available resources	Resources to be had inside the organization encompass the following:
Needed resources	Perceive what property will need to be supplied, which will ensure that the protection improvement plan is fulfilled.
Existing resources	Recognize what assets are already available that may be implemented, allowing you to maximize the development sketch.

Existing Organizational Resources:

• Identify resources that may need to be obtained for the success of the safety improvement plan. Consider what existing resources may be leveraged to enhance the improvement plan.

Item	Details
Funding support	Provide funding, and neighborhood funding will be maintained to help with those duties.
Haven partnership financing	Haven partnership financing will allow hospitals to contract with neighborhood shelters and transitional housing applications to provide strong post-discharge placements for patients, including Michael, and reduce readmission (Agbata et al., 2021).
Trauma-informed care training	ER, the body of humans, can be professional in trauma-knowledgeable care to become aware of implicit bias, observe deteriorating conditions, and incredible practices in homeless-affected individual interactions, which can also end Michael’s deteriorating contamination handled in advance.
Enhanced discharge planning	Increasing the involvement of ER nurses, case managers, and social workers in discharge-making plans will enhance care coordination to deliver the rights as great as possible to patients at high risk.
Integration of

References

1. https://doi.org/10.1002/cl2.1154
2. https://doi.org/10.3390/ijerph21020232
3. http://www.ncbi.nlm.nih.gov/books/NBK589697/
4. https://doi.org/10.1111/maq.12665
5. https://doi.org/10.1093/jamia/ocaa143
6. https://doi.org/10.1007/s40615-021-01119-z
7. https://doi.org/10.1007/s11606-020-06029-0