NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Student Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Root-Cause Analysis and Safety Improvement Plan
Completed by: _______
Organization: School of Nursing and Health Sciences, Capella University
Department: NURS4035: Improving Quality of Care and Patient Safety
Reported to: (Instructor Name)
Date Completed by: (Date)
This template is provided as an aid in organizing the steps in a root-cause analysis. Not all possibilities and questions will apply in every case, and there may be others that will emerge in the course of the analysis. However, all possibilities and questions should be fully considered in your quest for “root cause” and risk reduction.
A sentinel event is apatient safety eventthat occurs unexpectedlyand is not primarily related to the natural course of the patient’s illness or underlying condition.
These events aredebilitating not only for patients but also for the health care providers involved. The goal is to learn from these incidents, improve systems, and prevent further harm to patients
Remember, a thorough root-cause analysis aims to uncover both immediate causes and underlying systemic issues to prevent similar events in the future.
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
| Understanding What Happened | |
| 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. Who did the problem/event affect, and how? | Maria Thompson is a 45-year-old female patient, who presented herself to an emergency department with a severe pain in the abdomen in connection with the disease of the gallbladder. In the night shift, Maria was more irritated and verbally abusive when she was told that her surgery would be postponed because of an emergency case. The patient started shouting and swearing at the nurse on duty who tried to explain the situation and this gave a tense environment in the unit. The patient did not report the incident using the Workplace Violence (WPV) reporting system of the hospital since the nurse felt that the management would not attend to the complaint. In the next morning shift, Maria still had signs of hostile behavior, shouting at another nurse who was getting her ready to undergo diagnostic tests. The case brought about emotional pain and fear among the staff members because they felt unsupported and insecure. This affected the patient care in the unit, and other patients were delayed medical attention. This incident had an impact on the staff morale and teamwork and less focus on patient safety. The unstructured training on the prevention of the use of WPV, the absence of security personnel, and the inability to resort to the formal reporting systems led to the development of the situation (Lim et al., 2022). This case demonstrates that workplace violence is a phenomenon that can negatively affect the well-being of the staff and reduce the quality of provided care. |
| Why did it happen?:Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.System Factors: Examine workflow processes, equipment failures, and environmental factors.Organizational Culture: Assess if there are cultural issues, lack of safety culture, or inadequate leadership support.Society/Culture: What role might cultural assumptions or backgrounds play? | The incident involving Ms. Maria Thompson occurred as a result of several interrelated factors that can be categorized as human, system, organizational, and cultural contributors. Human Factors The primary human factor was the lack of effective de-escalation and communication skills among staff during the patient’s aggressive episode. The nurse on duty was working under high stress due to multiple patient demands and limited support. This impaired her ability to manage the situation calmly. Fatigue and emotional exhaustion from extended shifts reduced her situational awareness and response capacity. The staff lacked sufficient WPV prevention training, such as recognizing early signs of aggression and applying structured de-escalation techniques. The nurse’s decision not to report the incident reflected a lack of confidence in the reporting system and fear of being blamed or not supported by management. These human factors collectively contributed to the escalation of violence and compromised both staff safety and patient care (Lozano et al., 2021).System Factors There was no standardized reporting and alert system in place to document or flag incidents of workplace violence. The absence of an efficient electronic reporting mechanism limited timely communication between shifts and departments. This prevent leadership from identifying high-risk patients and patterns of aggression. The physical environment lacked proper safety measures such as panic buttons, clear exit routes, or designated security support. This increased staff vulnerability. These system shortcomings created conditions in which violent behavior could escalate unchecked and staff response was delayed (Lim et al., 2022). Organizational Culture An incident showed a poor safety culture, where nurses would not report violence or seek help out of fear of being blamed or that their concerns would not be taken seriously by the managerial level. The leadership did not confirm zero tolerance and visibly support affected employees. Organizational factors include rigid schedules for visits and linguistic or cultural barriers, which increase frustration and stress in patients, thereby enhancing the chances of aggression that affect staff and patients. The absence of debriefing or emotional support following violent episodes contributed to moral distress and burnout among staff. In the absence of a proactive safety culture that values safety and psychological well-being, incidents of workplace violence are bound to recur and affect patient care (Lim et al., 2022).Society/Culture The problem was exacerbated by social and cultural perceptions. Aggression from patients or family members is often minimized or normalized in healthcare settings as “part of the job,” which deters nurses from reporting such incidents. Different cultural perspectives on communication and authority can affect how nurses react to violent situations. Some nurses shy away from conflict out of deference or concern about things getting worse. Effective reporting and open communication are impeded by these cultural and societal barriers. In order to foster a secure and courteous healthcare environment, this incident emphasizes the necessity of an all-encompassing strategy that takes into account organizational, cultural, system, and human factors (Lozano et al., 2021). |
| Was there a deviation from protocols or standards?:Procedures and Policies: Determine if established protocols were followed or if there were deviations.Were there any steps that were not taken or did not happen as intended?Documentation: Review medical records, nursing notes, and other relevant documentation. | The case of Ms. Thompson showed that indeed there is a breach of workplace violence prevention procedures and reporting policies in the hospital. The organization had a written policy, which demanded that employees should report any verbal or physical aggression cases through an electronic system of reporting the verbal or physical violence, which was known as the electronic WPV system and also report such cases to the security personnel. Nevertheless, the nurse in the incident failed to use the established reporting procedure as she thought that the incident would not be taken seriously. No report on the WPV or security alert was made, and the incident was reported orally to the charge nurse, which led to the lack of any formal records and follow-up (Foster et al., 2022).Besides, the policy of the hospital focused on the use of de-escalation guidelines and prompt team-based reaction in case of aggressive patients, yet the staff had not undergone regular training in the prevention of WNV and de-escalation. The system did not have documented incident reporting and was ignorant of the escalating behavior of the patient and exposed other staffs to further risks. The review of documentation showed that the hospital had a functional but not utilized component of the reporting of WPV because of a lack of confidence among the staff and no management response to this issue. This failure to follow the usual reporting and prevention policies helped the violence to grow, emotional trauma of staff members, and the interruption of care provision. Evidence-based research has shown that non-adherence to policies of the WPV and a lack of reporting on violence cases heighten employee burnout, anxiety, and turnover (Lozano et al., 2021). This will jeopardize the safety of employees and patients. |
| Who was involved?:Staff: Identify the roles of individuals directly involved in the event.Supervisors and Managers: Investigate | The workplace violence incident of Ms. Thompson directly or indirectly involved several healthcare professionals. The night shift nurse was most affected, since she was the one who was in charge of the care of the patient and the one who received verbal aggression. Although hospital policy claims that all the violent incidences should be reported immediately using the electronic WPV reporting system. The nurse failed to report the incidence as she was afraid of being blamed and had no confidence that she would be supported by the management. The charge nurse in charge was implicated indirectly, since she was verbally notified of the behavior of the patient, but failed to embark on formal reporting or alert security, as is the case (Di Prinzio, 2023).The same patient later went on to continue aggression towards the morning shift nurse, which meant that the lack of documentation and communication enabled the risk to continue. The physician in charge, who knew that the patient was agitated, did not cooperate with the nursing staff to use behavioral management interventions or order a behavioral health consult. The nurse manager assessed the incident retrospectively and mentioned the lack of communication, the absence of a reporting of the WPV. The violation of the safety policy, as some of the factors that led to the incident. It has been demonstrated that underreporting and absence of interprofessional coordination of the incidents of the WPV lead to a tremendous rise in the frequency of the incident, distress in staff, and breakdown in patient care (Di Prinzio, 2023). |
| Was there a breakdown in communication?Interdisciplinary Communication: Assess how well different teams communicated.Patient-Provider Communication: Explore whether patients were informed and understood their care. | Indeed, there was a significant breakdown in communication between members of the healthcare team and the patient involved in Ms. Thompson’s workplace violence incident.Interprofessional Communication Communication failed among the interprofessional team before, during, and after the violent episode. The night shift nurse verbally reported that the patient had become increasingly agitated. Still, this information was not conveyed using the standardized SBAR format or documented in the WPV reporting system. The day shift staff were unaware of the escalating risk and were unprepared to implement preventive safety measures. The charge nurse and physician were informed informally but did not initiate a behavioral alert or de-escalation plan, reflecting poor coordination and unclear role accountability. Studies emphasize that ineffective interprofessional communication is a leading contributor to repeated WPV incidents, staff injury, and emotional trauma (Somani et al., 2021).Patient/Provider Communication Communication between the nurse and the patient lacked therapeutic engagement strategies that have prevented escalation. The patient’s frustration and aggression were not adequately addressed through de-escalation dialogue or supportive communication, as required by WPV prevention protocols. The absence of active listening and conflict resolution techniques prevented early intervention. Effective communication, transparency, and patient involvement in care discussions are essential in mitigating violence and developing a safer environment for staff and patients (Somani et al., 2021). |
| What were the contributing factors?:Physical Environment: Consider facility layout, equipment availability, and workspaces.Staffing Levels: Evaluate if staffing was adequate.Training and Competency: Assess staff’s knowledge and skills. | The incident that involved Ms. Thompson was caused by a number of factors, which comprised physical environment issues, staffing, and training.Physical EnvironmentThe physical layout of the unit heightened the chances of violence at the workplace. The nurses had patient rooms far away, which did not allow the staff to see and immediately respond to increasing behaviours. The ward was busy and very noisy such that nurses could not easily monitor patients and communicate in a short time in case of aggressive episodes. Moreover, security protocols, including panic buttons, surveillance cameras, and clear exit paths, were either inadequate or not readily available to staff members, thus slowing down the response of the staff to violent outbreaks (Lim et al., 2022). All these environmental factors led to poor working conditions to staff and patients.Staffing LevelsThis event took place on a night shift when there was a decrease in staffing. Nurses had several high-acuity patients, which led to time constraints and augmented fatigue. The night nurse was forced to serve other patients and to deal with the aggressive patient and this reduced her capabilities to enact de-escalation measures and to report the incident to the authorities at hand. The staffing shortage was one of the factors that led to delaying interventions and increasing the probability of recurring aggressive incidents (Arnetz, 2022).Training and CompetencyDespite the policies that had been implemented in the hospital, which mandated that all the staff undergo training on the prevention of WPV and de-escalation measures, not every employee had been educated to competency tests regularly. Most of the nurses were not experienced in the detection of any early signs of aggression and the use of systematic de-escalation strategies. Staff confidence and preparedness were lowered because of the lack of continuous training, simulation activities, and skill reinforcement. These training and competency gaps in the case of Ms. Thompson were directly related to the increase in violence and the further threat of the safety of both staff and patients (Kumari et al., 2022). |
| Did organizational policies or procedures play a role?:Policy Compliance: Investigate if policies were followed.Policy Clarity: Assess if policies are clear and accessible. | Organizational policies and procedures had a impact on the incident involving Ms. Thompson. Hospital policies are designed to create standardized processes that protect staff and patients, promote safety, and safeguard quality care. In this case, the hospital had policies requiring staff to report all incidents of verbal or physical aggression through the electronic WPV reporting system and to follow de-escalation protocols during patient interactions (Arnetz, 2022). However, these policies were not consistently applied. The night shift nurse did not document the patient’s aggressive behavior, did not notify security, and did not follow structured de-escalation steps. This allowed the escalation to continue into the morning shift. The policies were not clearly communicated or reinforced. Many staff members were unaware of the exact reporting procedures or the expectations for timely intervention, and the policy documents were lengthy and not easily accessible during busy shifts, discouraging adherence. Leadership did not monitor compliance, conduct audits, or provide feedback on incident reporting. This weakening accountability and implicitly signaling that policies could be overlooked. Ultimately, poor policy communication, insufficient staff training, and a lack of oversight contributed directly to the unsafe environment, repeated aggression, and emotional distress among the care team (Lozano et al., 2021). |
| Was there a failure in monitoring or surveillance?:Vital Signs Monitoring: Check if there were any missed signs.Alarm Fatigue: Explore if alarms were ignored. | Well, yes, there was a lapse on the part of monitoring and surveillance in the care of Ms. Thompson and that is what led to the increase of workplace violence. The patient showed some of the initial signs of agitation, which included raised voice, pacing, and closed fists, but behavioral signs were not properly recorded and transferred to the next staff. The night nurse witnessed the aggression, but failed to highlight on the increasing behavior of the patient during the verbal handoff, and no formal report on the patient regarding the WPV was made. Environmental distraction and alarm fatigue could also have led to the failure; several patient alarms and regular unit noise distracted staff and made them ignore minor indicators of aggression. The lack of an organized monitoring procedure of high-risk or potentially violent patients minimized the chance of an early intervention, including security notification or behavioral de-escalation (Foster et al., 2022). These surveillance and response failures contributed to the escalation of the aggression of the patient, endangering the staff, emotionally traumatizing the patient, and interfering with safe patient care. |
| What can be learned to prevent recurrence?:Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.Quality Improvement: Consider implementing preventive measures. | The incident involving Ms. Thompson provides important lessons for preventing similar workplace violence events in the future. First, standardized reporting and communication protocols for WPV incidents must be consistently used across all units. Staff should be trained to follow evidence-based procedures, including timely documentation in the electronic WPV reporting system and use of structured de-escalation strategies, reinforced through simulation exercises and competency assessments (Somani et al., 2021). Electronic reporting tools include alerts and tracking features to safeguard that all care providers are aware of patients with a history of aggression. This allows for safety measures and decreases the chances of repeated episodes of violence (Foster et al., 2022). Effective leadership is vital in developing a safety culture. This includes urging staff members to report incidents without fear of blame and ensuring timely interventions. Regular audits, feedback and monitoring of compliance with the policies on WPV promote compliance. Simulation-based and cognitive-behavioral training are important strategies to prevent WPV (Yosep et al., 2023). Optimization of electronic reporting systems improves the usability, accuracy of incident documentation (Foster et al., 2022). Multidisciplinary coordination among nurses, behavioral health experts and security teams guarantees timely intervention and improves patient and staff safety. Responding to staffing shortages and high patient-to-nurse ratios reduces fatigue. This improves situational awareness, and allows staff sufficient time to implement violence prevention approaches (Foster et al., 2022). These quality improvement methods improve communication and provide a safer care setting. |
| How can patient safety be enhanced?:Risk Mitigation: Develop strategies to minimize risks.Education and Training: Ensure staff are well-trained.Reporting and Feedback: Encourage open reporting and learning from mistakes. | Patient and staff safety can be enhanced through a combination of risk mitigation strategies, continuous education, and a strong reporting culture.Risk MitigationHospitals should use standardized WPV prevention tools, such as electronic reporting templates and structured reporting protocols, to mitigate risk. Enhancing nurses’ coping and de-escalation skills through cognitive-behavioral and simulation-based training is an efficient strategy (Yosep et al., 2023). Staff can respond by setting aside time to monitor high-risk patients without interruption and by adding alerts to the electronic system when aggressive behavior is observed. To lessen fatigue, enhance situational awareness, and give nurses more time to employ de-escalation techniques, adequate staffing and workload management are vital (Arnetz, 2022) .Education and Training Ongoing training programs and simulation-based learning should be introduced to strengthen staff skills in recognizing early signs of aggression, applying de-escalation techniques, and managing violent situations safely. Regular competency assessments ensure consistent application of WPV prevention protocols and reinforce staff confidence (Qasem & Gillespie, 2025).Reporting and Feedback Establishing a non-punitive WPV reporting system inspires staff to report incidents or near-misses without fear of blame. Leadership should review reports. They provide timely feedback, and use incident data to implement system improvements rather than assign fault. Regular safety meetings, debriefings, and open discussions can identify trends in violent behavior and guide preventive measures. These efforts promote a culture of safety, accountability, and improvement, reducing the risk of WPV and safeguarding staff and patients (Qasem & Gillespie, 2025). |
Root Cause(s) to the issue or sentinel event?
Upon completion of the analysis above, please explicitly state one or more root causes that led to the issue or sentinel event. Please refer to the factors discussed above and categorize each root cause by choosing all that apply.
| Root Cause – the most basic reason that the situation occurred | Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal | HFC | HF T | HFF/S | E | R | B | |
| Ineffective reporting and communication regarding aggressive patient behaviors, insufficient staff training in de-escalation techniques, and staffing shortages leading to delayed recognition and management of workplace violence incidents. | 1 | Lack of standardized WPV reporting protocols, missed documentation of early warning signs of aggression, and no verification of prior interventions or security alerts. | ✅ | |||||
| 2 | Inconsistent training on WPV prevention and de-escalation techniques; no periodic skills assessment or competency evaluation for managing aggressive behaviors. | ✅ | ||||||
| 3 | Heavy workload, multitasking during high-risk patient care, and time pressures contributing to delayed reporting and inadequate management of aggressive behaviors. | ✅ |
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
Identify evidence-based best practice strategies to address the safety issue or sentinel event.
| Evidence-based studies have found that there are numerous best practice strategies of minimizing risks related to workplace violence in healthcare facilities. Research shows that underreporting and mismanagement of acts of violence are the primary factors that lead to recurring staff injuries, emotional distress, and impaired patient care (Lim et al., 2022). Such structured reporting instruments, as standardized electronic WPV reporting systems alongside well-defined de-escalation guidelines have been proved to enhance documentation, timely response, and staff responsibility (Qasem & Gillespie, 2025). Foster et al. (2022) indicated that the use of an electronic system of the reporting of the incidences of the phenomenon of the use of the word of mouth, which includes alert characteristics, has led to a significant increase in the rate of reporting the incidents and the ability to prevent the situation by taking measures before it grows out of control. Role-playing and simulation training can provide staff with a higher level of competency in the competency of identifying the signs of aggression at an early stage and applying de-escalation methods in a secure setting. Patient interactions, designation of quiet and secure places and well-monitored space also alleviates stressors in the environment that may cause violent behavior. Once healthcare organizations integrate structured reporting instruments, technological integration, specific training, and favorable working conditions, staff safety is enhanced, patient care is safeguarded, and workplace violence cases can be efficiently avoided (Qasem and Gillespie, 2025). |
Explain how the strategies could be applied in the safety issues or sentinel events you have identified.
| In the case of Ms. Thompson, workplace violence had happened partly because of poor communication and poor reporting between the night staff and the morning staff which contributed to the escalation of aggressive behaviors. Evidence-based practices can be utilized in averting such incidents. Standardized electronic WPV reporting systems along with clear de-escalation protocols should be used to ensure that staff members present relevant, uniform, and practical information regarding patients with aggressive behaviors through the use of structured reporting frameworks. In the case of Ms. Thompson, the night nurse might have made a note of the initial signs of trouble, progressive behaviors, and interventions already initiated to give the day team a clear outline of how to avoid additional episodes. The process is facilitated by integrating electronic reporting tools, which automatically indicate the presence of high-risk patients and notify incoming staff about the actions that they have to complete, such as security notifications or behavioral health consultations (Somani et al., 2021). Training and role-playing exercises via simulation can be used to build confidence and competence of the staff in dealing with aggressive patients and enhance their ability to respond under high-stress conditions. Lastly, design of calm, safe, and well-supervised spaces to interact with patients helps to decrease environmental stimuli and distraction of the staff, enabling them to concentrate on early intervention. A mixture of systematic reporting, online assistance, specific training, and environmental adaptations would have minimized the threat of development, prevented injuries among employees, and reinforced a safety culture (Arnetz, 2022). |
Safety Improvement Plan
List any future actions needed to prevent reoccurrence.
| Action PlanOne for each Root Cause/Contributing Factor from above | E / C / AChoose one | |
| 1 | Implement mandatory use of a standardized WPV reporting and de-escalation protocol for all staff; provide refresher training and monitor compliance through periodic audits of incident reports. | C |
| 2 | Integrate an electronic WPV reporting template into the EHR to ensure automatic documentation of aggressive behaviors, interventions used, and alerts for incoming staff. | E |
| 3 | Conduct simulation-based WPV and de-escalation training for all nursing staff to improve confidence, teamwork, and effectiveness in managing aggressive patient behaviors. | C |
E = eliminate (i.e. piece of equip is removed, fixed or replaced.)
C = control (i.e. additional step/warning is added or staff is educated/re-educated)
A = accept (i.e. formal or informal discussions of “don’t let it happen again” or “pay better attention” but nothing else will change and the risk is accepted).Describe any new processes or policies and/or professional development that will be undertaken to address the root cause(s).
| In order to deal with the predisposing factors that led to the workplace violence case involving Ms. Thompson, a number of new procedures, policies, and professional development plans will be introduced.New Processes and PoliciesThe organization will implement a mandatory policy on prevention and reporting of aggressive behaviors in the workplace that will obligate all the nursing staff to report the aggressive behavior, adhere to established de-escalation guidelines, and use the electronic system of reporting the aggressive behavior WPV. Adherence will be checked by regularly auditing and conducting follow-ups (Lim et al., 2022). The hospital will include an electronic reporting template in its EHR to make sure that the patient aggression, previous interventions, and security alerts are automatically presented to new employees to allow them to manage them. There will be specific safe and closely supervised patient care zones, which will decrease environmental triggering and interruption, and the staff will be able to pay attention to early recognition and de-escalation.Professional DevelopmentContinuous training and competency tests will be implemented to enhance the proficiency of the staff in identifying the initial signs of aggression, de-escalation methods, and dealing with violence incidents in a safe manner. The simulation workshops will enable the staff to learn through real life situations and get feedback to reinforce the working strategies. Leadership will help to create a safety culture through open communication, non-punitive reporting of incidents, and helping staff in making intervention decisions (Qasem & Gillespie, 2025). These efforts will raise the level of staff readiness, collaboration, and responsibility, which will eventually lead to the safety of not only medical staff but patients. |
Provide a description of the goals or desired outcomes of the actions listed above, along with a rough timeline of development and implementation for the plan.
| Goals and Desired Outcomes The overall objective of the effort to increase safety is to minimize the cases of workplace violence and enhance the readiness of the staff to deal with the aggressive behavior. The intended results will be to have timely reporting of violent cases, ensure the application of de-escalation measures, enhance staff responsibility, and a statistically significant decrease in staff injuries and emotional distress. It is anticipated that the standardization of the reporting and prevention of the use of violent force will lead to an 100 percent rate of reporting of the incidents and using the structured de-escalation procedures, which will result in a reduction of the quantity of the reported cases of violent force by at least 30 percent and more in the first year. The program will be used to enhance the safety culture, whereby the employees will be empowered to freely communicate and take action on any signs of aggression before it escalates without fear of being reprisal.Timeline for Development and Implementation Month 1–2: Review and update hospital policies to include mandatory WPV reporting and de-escalation protocols. Develop electronic WPV reporting templates. Month 3–4: Train all nurses and healthcare staff on the new WPV policies, reporting procedures, and de-escalation techniques. Month 5–6: Launch pilot execution in one hospital unit; gather feedback and refine reporting and intervention procedures. Month 7–12: Expand hospital-wide implementation; conduct compliance audits, performance evaluations, and review outcomes related to violence prevention and staff safety. Ongoing: Annual training refreshers, quarterly safety reviews, and continuous improvement based on staff feedback and incident reports. |
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.
| The effectiveness of the safety improvement plan targeted at workplace violence prevention will be based on the existing organizational resources and new resources that might be required to be purchased. The hospital presently possesses an electronic health record (EHR) system which is modified to encompass an incorporated WPV reporting template with notices of high-risk patients. Available in-service training and simulation laboratories can give knowledge of how to identify the initial signs of aggression, methods to de-escalate and methods to intervene safely. Nurse managers, Quality Improvement (QI) teams, and clinical educators can offer oversight, follow metrics of incidents, observe the adherence to the policies of the WPV, and coach. Timely interventions can be facilitated with the help of current technology, such as secure messaging and reporting dashboards, which will be used to provide real-time information about aggressive behaviors (Arnetz, 2022). Moreover, it is possible to use TeamSTEPPS as an extraneous resource that will help to enhance communication and collaboration in dealing with violent or aggressive circumstances. Other resources can be IT assistance in changing EHR to improve automatic notification of high-risk patients, financial support of simulation-based workshops on working with the WPV, and educational materials to educate the personnel on organizing reports and de-escalation measures. The staffing can be adjusted to provide sufficient coverage to take care of high-risk patients. Changes to the environment, such as safe, calm, and well-supervised spaces needed to minimize factors that provoke aggression (Qasem & Gillespie, 2025). Integrating the current and new resources will enhance the credibility of the practice of preventing falls by the use of the CPOE, increase the confidence of the staff and the success of the staff, and promote a culture of safety sustainability among the staff and patients. |
Reference
Arnetz J. E. (2022). The Joint Commission’s new and revised workplace violence prevention standards for hospitals: A major step forward toward improved quality and safety. Joint Commission Journal on Quality and Patient Safety, 48(4), 241–245. https://doi.org/10.1016/j.jcjq.2022.02.001
Di Prinzio, R. (2023). The management of workplace violence against healthcare workers: A multidisciplinary team for total worker health® approach in a hospital. ProQuest, 20(1), 196. https://doi.org/10.3390/ijerph20010196
Foster, M., Adapa, K., Soloway, A., Francki, J., Stokes, S., & Mazur, L. M. (2022). Electronic reporting of workplace violence incidents: Improving the usability, and optimizing healthcare workers’ cognitive workload, and performance. In MEDINFO 2021: One world, one health – Global partnership for digital innovation (pp. 425–429). IOS Press. https://www.researchgate.net/publication/361140268_Electronic_Reporting_of_Workplace_Violence_Incidents_Improving_the_Usability_and_Optimizing_Healthcare_Workers’_Cognitive_Workload_and_Performance
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Kumari, A., Sarkar, S., Ranjan, P., Chopra, S., Kaur, T., Baitha, U., Chakrawarty, A., & Klanidhi, K. B. (2022). Interventions for workplace violence against health-care professionals: A systematic review. Work, 73(2), 1–13. https://doi.org/10.3233/wor-210046
Lim, M. C., Jeffree, M. S., Saupin, S. S., Giloi, N., & Lukman, K. A. (2022). Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Annals of Medicine and Surgery, 78(103727), 103727. https://doi.org/10.1016/j.amsu.2022.103727
Lozano, J. M., Ramón, J. P., & Rodríguez, F. M. (2021). Doctors and nurses: A systematic review of the risk and protective factors in workplace violence and burnout. International Journal of Environmental Research and Public Health, 18(6), 3280. https://doi.org/10.3390/ijerph18063280
Qasem, I., & Gillespie, G. L. (2025). Intervention and strategies to prevent workplace violence from patients and visitors against nurses: An integrative review. Journal of Advanced Nursing, 81(11). https://onlinelibrary.wiley.com/doi/10.1111/jan.70192
Somani, R., Muntaner, C., Hillan, E., Velonis, A. J., & Smith, P. (2021). A systematic review: Effectiveness of interventions to de-escalate workplace violence against nurses in healthcare settings. Safety and Health at Work, 12(3), 289–295. https://doi.org/10.1016/j.shaw.2021.04.004
Yosep, I., Mardhiyah, A., Hendrawati, H., & Hendrawati, S. (2023). Interventions for reducing negative impacts of workplace violence among health workers: A scoping review. Journal of Multidisciplinary Healthcare, 16, 1409–1421. https://doi.org/10.2147/JMDH.S412754