Improving Nursing Practice Through Root-Cause Analysis and Quality Improvement

Assessment Brief

Course: NURS4035: Improving Quality of Care and Patient Safety
Assessment 3: Root-Cause Analysis and Safety Improvement Plan
Due Date: (Insert Date)
Weight: 25% of final grade
Length: 5–7 pages (excluding title page and references)
Format: APA 7th edition

Assessment Task Description

Purpose

This assessment challenges you to analyze a sentinel event through a structured root-cause analysis (RCA) framework, identify contributing factors, and design a patient safety improvement plan supported by evidence-based strategies. The purpose is to develop your critical thinking in identifying systemic issues in healthcare and to foster leadership skills in advancing a culture of safety.

Scenario

Imagine you are part of a hospital safety and quality team tasked with investigating a recent sentinel event. As the nurse leader, you must perform a root-cause analysis to determine what happened, why it happened, and how to prevent recurrence.

Task Instructions

1. Root-Cause Analysis (RCA)

   • Describe the sentinel event (real or simulated).

   • Identify key contributing factors (human, system, environmental, communication, policy).

   • Evaluate whether there was a deviation from protocols, procedures, or standards.

   • Analyze documentation, communication pathways, and organizational culture as they relate to the event.

2. Application of Evidence-Based Strategies

   • Identify at least three evidence-based best practices relevant to the sentinel event.

   • Discuss current literature (2019–2025) supporting interventions to reduce risks.

   • Provide rationale for how these strategies can prevent recurrence.

3. Safety Improvement Plan

   • Develop an actionable plan addressing each identified root cause.

   • Propose interventions that may include:

     • Eliminating risk factors (e.g., replacing faulty equipment)

     • Controlling risks (e.g., standardized checklists, staff re-education)

     • Accepting residual risk (when unavoidable)

   • Establish measurable goals, a timeline for implementation, and monitoring/evaluation strategies.

4. Organizational Resources & Implementation

   • Assess existing resources within the healthcare organization.

   • Identify additional resources required (e.g., training programs, staffing, technology).

   • Discuss leadership, communication, and reporting structures needed for sustainability.

5. Conclusion

   • Summarize key lessons learned.

   • Reflect on implications for nursing practice and patient safety culture.

Assessment Criteria (Rubric Highlights)

• Comprehension & Analysis (30%): Depth of RCA, identification of root causes, and systemic thinking.

• Application of Evidence (25%): Integration of peer-reviewed, evidence-based practices (2019–2025).

• Plan Development (25%): Clear, actionable, feasible improvement plan with outcomes.

• Organization & Academic Writing (20%): APA compliance, logical flow, clarity, scholarly tone.

References

1. Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

2. Okuyama, A., Wagner, C., & Bijnen, B. (2019). Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Services Research, 19(1), 1–8. https://doi.org/10.1186/s12913-018-3869-9

3. Hwang, J., & Lee, S. (2022). Nurse staffing levels and patient safety: A systematic review. Healthcare, 10(9), 1792. https://doi.org/10.3390/healthcare10091792

4. O’Brien, B. C., King, R., & Holmes, D. (2021). Root cause analysis and safety culture: Integrating methods to enhance learning from adverse events. Journal of Nursing Care Quality, 36(4), 321–327. https://doi.org/10.1097/NCQ.0000000000000549

5. Poon, E. G., et al. (2020). Medication safety and the role of electronic prescribing systems: A systematic review. BMJ Quality & Safety, 29(1), 12–23.