Root Cause Analysis

Assignment Overview:

In this assignment, you will apply the Root Cause Analysis (RCA) framework to evaluate a sentinel event. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. These events often signal the need for immediate investigation and response.

As a masters-prepared nurse, you are expected to take part in systems-level thinking, quality improvement (QI), and safety planning. This activity will help you develop those competencies by analyzing an event, identifying contributing factors, and recommending actionable improvements.

Instructions:

Step 1: Choose a Sentinel Event

Select a real or hypothetical sentinel event. Examples include:

• Medication error resulting in harm
• Wrong-site surgery
• Delay in treatment
• Patient suicide in a healthcare setting
• Hospital-acquired infection leading to death

Do not include any real patient identifiers (PHI). You may draw from your own experiences, a de-identified case from clinical practice, or a published event (e.g., from The Joint Commission or news reports).

Step 2: Analyze the Event Using the RCA Framework

Use the following structure for your written analysis (23 pages, not including title/reference pages):

1. Brief Summary of the Event

• What happened? When and where did it occur?

1. Identify the Root Causes

• What were the contributing factors?
• Consider human, environmental, communication, and systems-level issues.

1. Propose Corrective Actions

• What could have been done differently?
• Suggest at least two specific systems-level improvements to reduce risk.

1. Role of the Advanced Practice Nurse

• How could a masters-prepared nurse contribute to QI in this scenario?
• Include references to AACN Essentials or QSEN competencies.

Step 3: Format and Submit

• Format your paper using APA 7th edition (title page, double spacing, references).
• Include at least two scholarly references (course materials or peer-reviewed literature).
• Submit your paper as a Word or PDF file via Canvas by the deadline.