NURS4020: Improving Quality of Care and Patient Safety

Root-Cause Analysis and Safety Improvement Plan

Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.

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Analysis of the Root Cause

Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:

What happened?
Who detected the problem/event?
Who did the problem/event affect?
How did it affect them?

Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:

What was supposed to occur?
- Were there any steps that were not taken or did not happen as intended?
What environmental factors (controllable and uncontrollable) had an influence?
What equipment or resource factors had an influence?
What human errors or factors may have contributed?
Which communication factors may have contributed?

These questions are just intended as a starting point. After analyzing the event, make sure you explicitly state one or more root causes that led to the issue or sentinel event.

Application of Evidence-Based Strategies

Identity best practices 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 addressed in safety issues or sentinel events.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Provide a description of a safety improvement plan that could realistically be implemented within the health care setting in which your chosen issue or sentinel event took place. This plan should contain:

Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
- Support these recommendations with references from the literature or professional best practices.
A description of the goals or desired outcomes of these actions.
A rough timeline of development and implementation for the plan.

Existing Organizational Resources

Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.

A brief note on resources that may need to be obtained for the success of the plan.
Consider what existing resources may be leveraged to enhance the improvement plan?

Conclusion

References

Reference page should be double spaced throughout without extra spaces between entries.

Each reference page entry should be formatted according to APA 7 guidelines with a hanging indent as is seen here.