For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue in a healthcare setting

Root-Cause Analysis and Safety Improvement Plan

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 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 a patient safety event that occurs unexpectedly and is not primarily related to the natural course of the patient’s illness or underlying condition.

These events are debilitating 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.

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?
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?
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.
Who was involved?: Staff: Identify the roles of individuals directly involved in the event. Supervisors and Managers: Investigate
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.
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.
Did organizational policies or procedures play a role?: Policy Compliance: Investigate if policies were followed. Policy Clarity: Assess if policies are clear and accessible.
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.
What can be learned to prevent recurrence?: Lessons Learned: Identify systemic changes, training needs, and improvement opportunities. Quality Improvement: Consider implementing preventive measures.
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.

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	HF F/S	E	R	B

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.

(Describe what the literature states about the factors that lead to the safety issue)

(For example, interruptions during medication administration increase the risk of medication errors by specifically stated data.)

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

Safety Improvement Plan

List any future actions needed to prevent reoccurrence.

Action Plan One for each Root Cause/Contributing Factor from above			E / C / A Choose one

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).

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.

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.

References: