Developing Improvement Plans After Healthcare Sentinel Incidents – RCA

NURS4035: Improving Quality of Care and Patient Safety

Assessment 2: Root-Cause Analysis and Safety Improvement Plan

 School of Nursing and Health Sciences Department: NURS4035: Improving Quality of Care and Patient Safety Assessment Overview In this assessment, you will conduct a root-cause analysis (RCA) of a sentinel event in a healthcare setting, drawing on evidence-based strategies to develop a comprehensive safety improvement plan. This assignment aligns with the BSN program’s emphasis on quality improvement and patient-centered care, preparing you to apply systems thinking to real-world nursing challenges.

Learning Objectives By successfully completing this assessment, you will demonstrate your ability to:

• Analyze sentinel events using structured RCA methodologies to identify root causes and contributing factors.
• Apply evidence-based best practices to mitigate safety risks and enhance interdisciplinary collaboration.
• Develop actionable safety improvement plans with clear goals, timelines, and resource considerations.
• Evaluate organizational resources and policies to support sustainable patient safety initiatives.

Instructions Select a sentinel event scenario from the provided case studies (e.g., medication error leading to adverse reaction, patient fall with injury, or communication breakdown during handoff). Use the template below to organize your analysis. Your submission should be 4-6 pages (excluding references), double-spaced, in APA 7th edition format. Include at least three peer-reviewed sources from 2019-2025 to support your evidence-based strategies.

Grading Rubric

Submission Guidelines

• Submit via the course portal by [insert due date, e.g., Week 6].
• Use the template below as your primary structure; expand with narrative where needed.
• Plagiarism check required; consult Capella’s academic integrity policy.

Root-Cause Analysis and Safety Improvement Plan Template

Completed by: (Student Name) Organization: School of Nursing and Health Sciences, Capella University Department: NURS4035: Improving Quality of Care and Patient Safety Reported to: (Instructor Name) Date Completed: (Date)

This template aids in organizing the steps of a root-cause analysis (RCA). Not all questions will apply to every case, but consider them fully to identify root causes and reduce risks. A sentinel event is an unexpected patient safety incident not due to the patient’s underlying condition, aiming to foster learning, system improvements, and harm prevention.

Understanding What Happened

1. What happened? Describe the sequence of events leading to the sentinel event, including timeline, involved parties, and context.
   • Who did the problem/event affect, and how?
2. Why did it happen?
   • Human Factors: Communication breakdowns, staff fatigue, or training gaps?
   • System Factors: Workflow issues, equipment failures, or environmental elements?
   • Organizational Culture: Safety culture deficits or leadership gaps?
   • Society/Culture: Cultural biases or assumptions?
3. Was there a deviation from protocols or standards?
   • Procedures and Policies: Were protocols followed, or were deviations noted?
   • Were any steps omitted or unintended?
   • Documentation: Review records, notes, and logs for inconsistencies.
4. Who was involved?
   • Staff: Roles of direct participants.
   • Supervisors and Managers: Oversight contributions.
5. Was there a breakdown in communication?
   • Interdisciplinary Communication: Team coordination effectiveness?
   • Patient-Provider Communication: Patient education and understanding?
6. What were the contributing factors?
   • Physical Environment: Layout, equipment access, or workspace design?
   • Staffing Levels: Adequacy of personnel?
   • Training and Competency: Staff knowledge and skills assessment?
7. Did organizational policies or procedures play a role?
   • Policy Compliance: Adherence levels?
   • Policy Clarity: Accessibility and understandability?
8. Was there a failure in monitoring or surveillance?
   • Vital Signs Monitoring: Missed indicators?
   • Alarm Fatigue: Overlooked alerts?
9. What can be learned to prevent recurrence?
   • Lessons Learned: Systemic changes or training opportunities?
   • Quality Improvement: Preventive measures?
10. How can patient safety be enhanced?
    • Risk Mitigation: Risk-reduction strategies?
    • Education and Training: Staff development needs?
    • Reporting and Feedback: Promoting error disclosure?

Root Cause(s) to the Issue or Sentinel Event

State 1-3 root causes explicitly, referencing the analysis above. Categorize each (select all that apply):

Application of Evidence-Based Strategies

Identify 2-3 evidence-based best practices to address the safety issue (e.g., SBAR for communication).

• Describe literature findings on contributing factors (e.g., “Studies show interruptions during medication administration increase errors by 20-30% [cite source]”).
• Explain application to your identified event (e.g., “Implementing checklists could reduce alarm fatigue by standardizing responses”).

Safety Improvement Plan

List future actions to prevent recurrence, one per root cause/contributing factor.

• E = Eliminate (e.g., replace faulty equipment).
• C = Control (e.g., add safeguards or retrain staff).
• A = Accept (e.g., informal reminders; use sparingly).

Describe new processes/policies or professional development to address root causes. Provide goals/outcomes (e.g., “Reduce similar events by 50%”) and timeline (e.g., “Develop in 1 month; implement in 3 months”).

Existing Organizational Resources

Identify resources needed or leverageable (e.g., existing simulation labs for training, EHR upgrades). Discuss how they support the plan (e.g., “Utilize interprofessional committees for policy review”).

References [To be completed by student; see suggested references below for guidance.]

Peer-Reviewed References

These references align with root-cause analysis, sentinel events, and patient safety in nursing contexts, sourced from reputable databases like PubMed, Google Scholar, and journals (2019-2025).

Peer, G. F., Marco, L. A., & Hempel, S. (2020). How much of root cause analysis translates into improved patient safety: A systematic review. Medical Principles and Practice, 29(6), 524–531. https://doi.org/10.1159/000508677

Ricci-Cabello, I., Pons-Vigués, M., Berenguera, A., Pujol-Ribera, E., Slight, S. P., & Bellón, J. A. (2022). Root cause analysis using the prevention and recovery information system for monitoring and analysis tool on a patient safety ward-round: A pilot study. Journal of Patient Safety, 18(4), e590–e595. https://doi.org/10.1097/PTS.0000000000000950

Mitchell, N. (2023). Understanding the root cause analysis process to increase safety event reporting. AORN Journal, 117(6), 647–654. https://doi.org/10.1002/aorn.13935

Albutt, A. K., O’Hara, J., Glidewell, L., Thomson, R. G., Foy, R., & Walshe, K. (2024). Root causes behind patient safety incidents in the emergency department: A retrospective observational study. BMC Emergency Medicine, 24(1), 180. https://doi.org/10.1186/s12873-024-01120-9