Running head ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN .docx

Running head: ROOT-CAUSE ANALYSIS AND
IMPROVEMENT PLAN 1
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Root-Cause Analysis and Improvement Plan
Learner’s Name
Capella University
Improving Quality of Care and Patient Safety
March, 2019

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN
2
According to Spath (2011), root-cause analysis is a methodical
approach that aims to
discover the causes of adverse events and near misses for the
purpose of identifying
preventive measures (as cited in Charles et al., 2016). A root-
cause analysis of falls in
geropsychiatric patients was conducted at an inpatient mental
health unit. The paper describes
and analyzes falls and discusses evidence-based strategies to
reduce falls and determine a
safety improvement plan based on the utilization of existing
organizational resources to
address these falls.
Root-Cause Analysis of Falls in Geropsychiatric Inpatients
According to Murphy, Xu, and Kochanek (2013), the Centers
for Disease Control and

Prevention reported that falls were a leading cause of
unintentional injury death in adults
aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-
related injuries that can lead to
serious head trauma are common among older adults. Injury
falls are serious and could lead
to fractures, head injury, and intracranial bleed. According to
the National Quality Forum
(2011), injury falls in older adults are almost always
preventable (as cited in Powell-Cope et
al., 2014). Fall-related injuries prolong the stay of patients at
the hospital and aggravate their
health conditions (Powell-Cope et al., 2014).
Considering the adverse implications of falls in such patients, a
root-cause analysis
was conducted on the 20 cases of falls reported over a period of
one year at a geropsychiatric
inpatient facility. The aim of the analysis was to understand the
causes of falls in
geropsychiatric patients at the unit. The analysis was conducted
by a team of five experts
including clinicians, supervisors, and quality improvement
personnel. The cases reported had
been registered by a team of nurses who collated the data

related to the falls. All the falls
were described as cases of slipping or tripping, and patients
mostly sustained injuries
involving pain, mild swelling, and abrasions, with only two of
the cases involving minor
3
fractures. It was also observed that all the falls occurred near
the beds of patients and during
the evening or night shifts when nursing teams were more likely
to be understaffed.
Geropsychiatric patients are known to be susceptible to falls
under the influence of
drugs such as antidepressants and antipsychotics. Orthostatic
hypotension (decrease in blood
pressure within three minutes of standing), ataxia (lack of
voluntary muscular control caused
by injury to the central nervous system), and extrapyramidal
slowing (impaired motor

functions) due to the use of drugs such as antidepressants,
antipsychotics, sedatives,
hypnotics, alpha-blockers, and non-benzodiazepines are often
found to be linked to these
kinds of falls (Powell-Cope et al., 2014). The team of experts
reviewed the reports of falls
and noted that in over 50% of the cases, patients had been
ambulating under the influence of
drugs. It was also noted that 80% of the patients who fell while
ambulating under the
influence of drugs had been prescribed zolpidem.
At least 40% of the falls could be attributed to generalized
weakness, disorientation,
and difficulty with mobility. Fall and injury risks are often
complicated by behavioral
circumstances such as anger, anxiety, hyperarousal, and the
inability to call for help or to
remember to call for help. Physical conditions that occur with
substance abuse (such as
malnourishment and dehydration) co-exist with psychiatric
disability and cause further
complications (Powell-Cope et al., 2014).
Another factor that plays a role in patient safety is

infrastructure in hospitals. This was
particularly noteworthy as all the falls studied had occurred
when patients ambulated near
their beds. The use of beds with adjustable height, bed- and
chair-exit alarms, and nonskid
footwear are known to prevent fall-related injuries in
psychiatric patients (Powell-Cope et al.,
2014).
4
Application of Evidence-Based Strategies to Reduce Falls
Considering that all the falls reported occurred near the
patients’ beds, infrastructural
changes such as the installation of bed- and chair-exit alarms
are recommended. Falls from
beds are common in patients with cognitive impairments.
Installing electronic alarm systems
was found to be a feasible and effective fall prevention strategy

in such cases (Wong Shee,
Phillips, Hill, & Dodd, 2014).
Strategies such as team engagement and proactive planning to
avoid falls can be
implemented in inpatient geropsychiatric wards. Forming a
quality and patient safety team
can serve as an essential safety net and drive a proactive
approach rather than a reactive one
toward reducing sentinel events. Such a team could include
existing staff in the unit that are
selected based on their skills and experience. The primary focus
of the team would be to
identify, evaluate, measure, and improve processes and
activities related to patient safety
within the unit (Serino, 2015).
Better management of medication must be implemented to
reduce falls that occur
under the influence of drugs. Administering melatonin instead
of zolpidem reduces the level
of sedation. Lower levels of sedation reduce the frequency of
patients’ visits to the bathroom
at night as well as the aftereffects of sedatives in the morning
(Powell-Cope et al., 2014).

Improvement Plan
The improvement plan involves a two-pronged approach:
improving staff
effectiveness and coordination and implementing environmental
modifications. The first part
of the plan focuses on increasing the effectiveness of patient
monitoring and staff
coordination through intentional rounding, one-to-one
observation of patients, and increased
communication among staff. Intentional rounding is a system
wherein the nursing staff
conduct structured routine checks on patients at regular
intervals. The duration of intervals is
decided based on the needs of patients in the unit. Intentional
rounding is known to be
5
particularly effective in reducing falls (Morgan et al., 2016).
One-to-one observation is

recommended for high-fall-risk patients. One-to-one
observation of patients by moving them
close to the nurse’s station aids effective monitoring and
reduces the risk of falls. Sentinel
events can be prevented by promoting interdisciplinary
collaboration in health care. Good
communication and collaboration between physicians,
therapists, kinesio therapists, and
occupational therapists are essential in monitoring patient
activity (Powell-Cope et al., 2014).
The second part of the improvement plan focuses on
environmental modifications to
existing infrastructure in the unit to reduce falls. Installing
chair- and bed-exit alarms to alert
staff when a patient attempts to leave the chair or bed has
proven to be effective in reducing
falls. These alarms can be attached to the patient directly or to
the chair or bed the patient
uses (Wong Shee et al., 2014). Other recommended
environmental modifications include
using creative display signage beside patients’ beds. This could
be magnets next to the name
of a fall-risk patient on a white board or the sign of a leaf on a
patient’s bedroom door. Such

displays alert staff and visitors of the risk involved with each
patient. The use of nonslip
strips on floors (especially in bathrooms) and the installation of
geriatric-friendly sanitary
ware such as handrails, assist bars, shower chairs, and raised
toilet chairs enhance patient
safety (Powell-Cope et al., 2014). The attending staff in the unit
would have to be trained to
facilitate and monitor the use of environmental modifications
such as electronic alarms to
ensure their successful implementation.
It is crucial to identify and leverage existing organizational
resources when
implementing the improvement plan. The first part of the
improvement plan involves
utilizing the skills and expertise of existing staff members
rather than hiring new members to
assist in fall prevention. To improve monitoring of patients, the
staff members are trained on
intentional rounding techniques and one-to-one observation.
The environmental interventions
suggested in the second part of the plan involve the installation
of additional components to

6
existing hospital fixtures such as chairs, beds, doors, and floors.
Leveraging existing
resources reduces the overall cost and effort involved in
implementing the plan and ensures
minimal disruption to ongoing patient routines and staff-led
fall-prevention practices within
the unit.
Conclusion
Falls are the leading cause of unintentional injury deaths in
geropsychiatric patients
and are largely preventable. A root-cause analysis of falls in
such patients was conducted at
an inpatient mental health unit. Infrastructural gaps and
ambulation under the influence of
drugs were found to be primary factors that precipitated the
falls reported in the unit. The

paper discusses evidence-based strategies such as medication
management, installation of
electronic alarms, and formation of a quality and patient safety
team that would help reduce
falls. A two-pronged improvement plan was formed to
systematically reduce falls in the unit.
The plan involved improving staff effectiveness and
coordination and implementing
environmental modifications.
7
References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y.,
Caird, M. S., . . . Hake, M. E.
(2016). How to perform a root cause analysis for workup and
future prevention of
medical errors: A review. Patient Safety in Surgery, 10.

http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8
Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston,
C., & McCulloch, P. (2016).
Intentional rounding: A staff‐led quality improvement
intervention in the prevention
of patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.
http://dx.doi.org/10.1111/jocn.13401
Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M.,
Stewart, J., Melillo, C., …
Friedman, Y. (2014). A qualitative understanding of patient
falls in inpatient mental
health units. Journal of the American Psychiatric Nurses
Association, 20(5), 328–339.
https://doi.org/10.1177/1078390314553269
Serino, M. F. (2015). Quality and patient safety teams in the
perioperative setting. AORN
Journal, 102(6), 617–628. https://doi-
org.library.capella.edu/10.1016/j.aorn.2015.10.006
Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014).
Feasibility, acceptability, and
effectiveness of an electronic sensor bed/chair alarm in
reducing falls in patients with

cognitive impairment in a subacute ward. Journal of Nursing
Care Quality, 29(3),
253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054
https://doi-
org.library.capella.edu/10.1177/1078390314553269Root-Cause
Analysis and Improvement PlanRoot-Cause Analysis of Falls in
Geropsychiatric InpatientsApplication of Evidence-Based
Strategies to Reduce Falls
Running head: ROOT-CAUSE ANALYSIS AND
IMPROVEMENT PLAN 1

Learner’s Name
Capella University
Improving Quality of Care and Patient Safety
March, 2019
2
According to Spath (2011), root-cause analysis is a methodical
approach that aims to
discover the causes of adverse events and near misses for the
purpose of identifying
preventive measures (as cited in Charles et al., 2016). A root-
cause analysis of falls in
geropsychiatric patients was conducted at an inpatient mental
health unit. The paper describes

and analyzes falls and discusses evidence-based strategies to
reduce falls and determine a
safety improvement plan based on the utilization of existing
organizational resources to
address these falls.
Root-Cause Analysis of Falls in Geropsychiatric Inpatients
According to Murphy, Xu, and Kochanek (2013), the Centers
for Disease Control and
Prevention reported that falls were a leading cause of
unintentional injury death in adults
aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-
related injuries that can lead to
serious head trauma are common among older adults. Injury
falls are serious and could lead
to fractures, head injury, and intracranial bleed. According to
the National Quality Forum
(2011), injury falls in older adults are almost always
preventable (as cited in Powell-Cope et
al., 2014). Fall-related injuries prolong the stay of patients at
the hospital and aggravate their
health conditions (Powell-Cope et al., 2014).
Considering the adverse implications of falls in such patients, a
root-cause analysis

was conducted on the 20 cases of falls reported over a period of
one year at a geropsychiatric
inpatient facility. The aim of the analysis was to understand the
causes of falls in
geropsychiatric patients at the unit. The analysis was conducted
by a team of five experts
including clinicians, supervisors, and quality improvement
personnel. The cases reported had
been registered by a team of nurses who collated the data
related to the falls. All the falls
were described as cases of slipping or tripping, and patients
mostly sustained injuries
involving pain, mild swelling, and abrasions, with only two of
the cases involving minor
3
fractures. It was also observed that all the falls occurred near
the beds of patients and during

the evening or night shifts when nursing teams were more likely
to be understaffed.
Geropsychiatric patients are known to be susceptible to falls
under the influence of
drugs such as antidepressants and antipsychotics. Orthostatic
hypotension (decrease in blood
pressure within three minutes of standing), ataxia (lack of
voluntary muscular control caused
by injury to the central nervous system), and extrapyramidal
slowing (impaired motor
functions) due to the use of drugs such as antidepressants,
antipsychotics, sedatives,
hypnotics, alpha-blockers, and non-benzodiazepines are often
found to be linked to these
kinds of falls (Powell-Cope et al., 2014). The team of experts
reviewed the reports of falls
and noted that in over 50% of the cases, patients had been
ambulating under the influence of
drugs. It was also noted that 80% of the patients who fell while
ambulating under the
influence of drugs had been prescribed zolpidem.
At least 40% of the falls could be attributed to generalized
weakness, disorientation,
and difficulty with mobility. Fall and injury risks are often

complicated by behavioral
circumstances such as anger, anxiety, hyperarousal, and the
inability to call for help or to
remember to call for help. Physical conditions that occur with
substance abuse (such as
malnourishment and dehydration) co-exist with psychiatric
disability and cause further
complications (Powell-Cope et al., 2014).
Another factor that plays a role in patient safety is
infrastructure in hospitals. This was
particularly noteworthy as all the falls studied had occurred
when patients ambulated near
their beds. The use of beds with adjustable height, bed- and
chair-exit alarms, and nonskid
footwear are known to prevent fall-related injuries in
psychiatric patients (Powell-Cope et al.,
2014).
4

Application of Evidence-Based Strategies to Reduce Falls
Considering that all the falls reported occurred near the
patients’ beds, infrastructural
changes such as the installation of bed- and chair-exit alarms
are recommended. Falls from
beds are common in patients with cognitive impairments.
Installing electronic alarm systems
was found to be a feasible and effective fall prevention strategy
in such cases (Wong Shee,
Phillips, Hill, & Dodd, 2014).
Strategies such as team engagement and proactive planning to
avoid falls can be
implemented in inpatient geropsychiatric wards. Forming a
quality and patient safety team
can serve as an essential safety net and drive a proactive
approach rather than a reactive one
toward reducing sentinel events. Such a team could include
existing staff in the unit that are
selected based on their skills and experience. The primary focus
of the team would be to
identify, evaluate, measure, and improve processes and
activities related to patient safety

within the unit (Serino, 2015).
Better management of medication must be implemented to
reduce falls that occur
under the influence of drugs. Administering melatonin instead
of zolpidem reduces the level
of sedation. Lower levels of sedation reduce the frequency of
patients’ visits to the bathroom
at night as well as the aftereffects of sedatives in the morning
(Powell-Cope et al., 2014).
Improvement Plan
The improvement plan involves a two-pronged approach:
improving staff
effectiveness and coordination and implementing environmental
modifications. The first part
of the plan focuses on increasing the effectiveness of patient
monitoring and staff
coordination through intentional rounding, one-to-one
observation of patients, and increased
communication among staff. Intentional rounding is a system
wherein the nursing staff
conduct structured routine checks on patients at regular
intervals. The duration of intervals is
decided based on the needs of patients in the unit. Intentional
rounding is known to be

5
particularly effective in reducing falls (Morgan et al., 2016).
One-to-one observation is
recommended for high-fall-risk patients. One-to-one
observation of patients by moving them
close to the nurse’s station aids effective monitoring and
reduces the risk of falls. Sentinel
events can be prevented by promoting interdisciplinary
collaboration in health care. Good
communication and collaboration between physicians,
therapists, kinesio therapists, and
occupational therapists are essential in monitoring patient
activity (Powell-Cope et al., 2014).
The second part of the improvement plan focuses on
environmental modifications to
existing infrastructure in the unit to reduce falls. Installing
chair- and bed-exit alarms to alert

staff when a patient attempts to leave the chair or bed has
proven to be effective in reducing
falls. These alarms can be attached to the patient directly or to
the chair or bed the patient
uses (Wong Shee et al., 2014). Other recommended
environmental modifications include
using creative display signage beside patients’ beds. This could
be magnets next to the name
of a fall-risk patient on a white board or the sign of a leaf on a
patient’s bedroom door. Such
displays alert staff and visitors of the risk involved with each
patient. The use of nonslip
strips on floors (especially in bathrooms) and the installation of
geriatric-friendly sanitary
ware such as handrails, assist bars, shower chairs, and raised
toilet chairs enhance patient
safety (Powell-Cope et al., 2014). The attending staff in the unit
would have to be trained to
facilitate and monitor the use of environmental modifications
such as electronic alarms to
ensure their successful implementation.
It is crucial to identify and leverage existing organizational
resources when
implementing the improvement plan. The first part of the

improvement plan involves
utilizing the skills and expertise of existing staff members
rather than hiring new members to
assist in fall prevention. To improve monitoring of patients, the
staff members are trained on
intentional rounding techniques and one-to-one observation.
The environmental interventions
suggested in the second part of the plan involve the installation
of additional components to
6
existing hospital fixtures such as chairs, beds, doors, and floors.
Leveraging existing
resources reduces the overall cost and effort involved in
implementing the plan and ensures
minimal disruption to ongoing patient routines and staff-led
fall-prevention practices within
the unit.

Conclusion
Falls are the leading cause of unintentional injury deaths in
geropsychiatric patients
and are largely preventable. A root-cause analysis of falls in
such patients was conducted at
an inpatient mental health unit. Infrastructural gaps and
ambulation under the influence of
drugs were found to be primary factors that precipitated the
falls reported in the unit. The
paper discusses evidence-based strategies such as medication
management, installation of
electronic alarms, and formation of a quality and patient safety
team that would help reduce
falls. A two-pronged improvement plan was formed to
systematically reduce falls in the unit.
The plan involved improving staff effectiveness and
coordination and implementing
environmental modifications.
7

References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y.,
Caird, M. S., . . . Hake, M. E.
(2016). How to perform a root cause analysis for workup and
future prevention of
medical errors: A review. Patient Safety in Surgery, 10.
http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8
Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston,
C., & McCulloch, P. (2016).
Intentional rounding: A staff‐led quality improvement
intervention in the prevention
of patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.
http://dx.doi.org/10.1111/jocn.13401
Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M.,
Stewart, J., Melillo, C., …
Friedman, Y. (2014). A qualitative understanding of patient
falls in inpatient mental
health units. Journal of the American Psychiatric Nurses
Association, 20(5), 328–339.

https://doi.org/10.1177/1078390314553269
Serino, M. F. (2015). Quality and patient safety teams in the
perioperative setting. AORN
Journal, 102(6), 617–628. https://doi-
org.library.capella.edu/10.1016/j.aorn.2015.10.006
Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014).
Feasibility, acceptability, and
effectiveness of an electronic sensor bed/chair alarm in
reducing falls in patients with
cognitive impairment in a subacute ward. Journal of Nursing
Care Quality, 29(3),
253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054
https://doi-
org.library.capella.edu/10.1177/1078390314553269Root-Cause
Analysis and Improvement PlanRoot-Cause Analysis of Falls in
Geropsychiatric InpatientsApplication of Evidence-Based
Strategies to Reduce Falls
Running head: Root-Cause Analysis and SAFETY Improvement
Plan
ROOT-CAUSE ANALYSIS AND SAFETY IMPROVEMENT
PLAN

Root-Cause Analysis and Safety Improvement Plan
YOUR NAME
NURS-FPX4020
Capella University
Month, Year
Root-Cause Analysis
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.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
other 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.
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 enhance
the improvement plan?
References
1

2
Analyze the root cause of a patient safety issue or a specific
sentinel event in an organization.
Apply evidence-based and best-practice strategies to address a
safety issue or sentinel event.
Create a viable, evidence-based safety improvement plan.
Identify existing organizational resources that could be
leveraged to improve a safety improvement plan.
Communicate safety improvement plan using writing that is
clear, logical, and professional, with correct grammar and
spelling, using current APA style.
For this assessment, you will use a supplied template to conduct
a root-cause analysis of a quality or safety issue in a health care
setting of your choice and outline a plan to address the issue.
As patient safety concerns continue to be addressed in the
health care settings, nurses can play an active role in
implementing safety improvement measures and plans. Often
root-cause analyses are conducted and safety improvement plans
are created to address sentinel or adverse events such as
medication errors, patient falls, wrong-site surgery events, and
hospital-acquired infections. Performing a root-cause analysis
offers a systematic approach for identifying causes of problems,
including process and system-check failures. Once the causes of
failures have been determined, a safety improvement plan can
be developed to prevent recurrences. The baccalaureate nurse's
role as a leader is to create safety improvement plans as well as
disseminate vital information to staff nurses and other health
care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent
choice to complete the Quality and Safety Improvement Plan
Knowledge Base activity and to review the various assessment
resources, all of which will help you build your knowledge of
key concepts and terms related to quality and safety

improvement. The terms and concepts will be helpful as you
prepare your Root-Cause Analysis and Safety Improvement
Plan. Activities are not graded and demonstrate course
engagement.
Demonstration of Proficiency
By successfully completing this assessment, you will
demonstrate your proficiency in the following course
competencies and assessment criteria:
· Competency 1: Analyze the elements of a successful quality
improvement initiative.
· Apply evidence-based and best-practice strategies to address a
· Create a feasible, evidence-based safety improvement plan.
· Competency 2: Analyze factors that lead to patient safety
risks.
· Analyze the root cause of a patient safety issue or a specific
sentinel event within an organization.
· Competency 3: Identify organizational interventions to
promote patient safety.
· Identify existing organizational resources that could be
leveraged to improve a plan.
· Competency 5: Apply professional, scholarly, evidence-based
strategies to communicate in a manner that supports safe and
effective patient care.
· Communicate in writing that is clear, logical, and
professional, with correct grammar and spelling, using current
APA style.
Professional Context
Nursing practice is governed by health care policies and
procedures as well as state and national regulations developed
to prevent problems. It is critical for nurses to participate in
gathering and analyzing data to determine causes of patient
safety issues, in solving problems, and in implementing quality
improvements.
Scenario
For this assessment, you may choose from the following options

as the subject of a root-cause analysis and safety improvement
plan:
· The specific safety concern identified in your previous
assessment.
· The Vila Health: Root-Cause Analysis and Safety
Improvement Planning simulation.
· One of the case studies from the previous assessment.
· A personal practice experience in which a sentinel event
occurred.
Instructions
The purpose of this assessment is to demonstrate your
understanding of and ability to analyze a root cause of a
specific safety concern in a health care setting. You will create
a plan to improve the safety of patients related to the concern
based on the results of your analysis, using the literature and
professional best practices as well as the existing resources at
your chosen health care setting to provide a rationale for your
plan.
Use the Root-Cause Analysis and Improvement Plan Template
[DOCX] to help you to stay organized and concise. This will
guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following,
which corresponds to the grading criteria in the scoring guide.
Please study the scoring guide carefully so you understand what
is needed for a distinguished score.
· Apply evidence-based and best-practice strategies to address
the safety issue or sentinel event.
· Identify organizational resources that could be leveraged to
improve your plan.
APA style.
Example Assessment: You may use the following to give you an

idea of what a Proficient or higher rating on the scoring guide
would look like:
· Assessment 2 Example [PDF].
Additional Requirements
· Length of submission: Use the provided Root-Cause Analysis
and Improvement Plan template to create a 4–6 page root cause
analysis and safety improvement plan. A title page is not
required but you must include a reference list as per the
template.
· Number of references: Cite a minimum of 3 sources of
scholarly or professional evidence that support your findings
and considerations. Resources should be no more than 5 years
old.
· APA formatting: Format references and citations according to
current APA style.
Note: Your instructor may also use the Writing Feedback Tool
to provide feedback on your writing. In the tool, click the
linked resources for helpful writing information.
Portfolio Prompt: Remember to save the final assessment to
your ePortfolio so that you may refer to it as you complete the
final Capstone course.
For this assessment, you will use a supplied template to conduct
a root-cause analysis of a quality or safety issue in a health care
setting of your choice and outline a plan to address the issue.
As patient safety concerns continue to be addressed in the
health care settings, nurses can play an active role in
implementing safety improvement measures and plans. Often
root-cause analyses are conducted and safety improvement plans
are created to address sentinel or adverse events such as
medication errors, patient falls, wrong-site surgery events, and
hospital-acquired infections. Performing a root-cause analysis
offers a systematic approach for identifying causes of problems,
including process and system-check failures. Once the causes of
failures have been determined, a safety improvement plan can
be developed to prevent recurrences. The baccalaureate nurse's
role as a leader is to create safety improvement plans as well as

disseminate vital information to staff nurses and other health
care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent
choice to complete the Quality and Safety Improvement Plan
Knowledge Base activity and to review the various assessment
resources, all of which will help you build your knowledge of
key concepts and terms related to quality and safety
improvement. The terms and concepts will be helpful as you
prepare your Root-Cause Analysis and Safety Improvement
Plan. Activities are not graded and demonstrate course
engagement.
Demonstration of Proficiency
By successfully completing this assessment, you will
demonstrate your proficiency in the following course
competencies and assessment criteria:
· Competency 1: Analyze the elements of a successful quality
improvement initiative.
· Apply evidence-based and best-practice strategies to address a
· Competency 2: Analyze factors that lead to patient safety
risks.
sentinel event within an organization.
· Competency 3: Identify organizational interventions to
promote patient safety.
· Identify existing organizational resources that could be
leveraged to improve a plan.
· Competency 5: Apply professional, scholarly, evidence-based
strategies to communicate in a manner that supports safe and
effective patient care.
APA style.
Professional Context
Nursing practice is governed by health care policies and

procedures as well as state and national regulations developed
to prevent problems. It is critical for nurses to participate in
gathering and analyzing data to determine causes of patient
safety issues, in solving problems, and in implementing quality
improvements.
Scenario
For this assessment, you may choose from the following options
as the subject of a root-cause analysis and safety improvement
plan:
· The specific safety concern identified in your previous
assessment.
· The Vila Health: Root-Cause Analysis and Safety
Improvement Planning simulation.
· One of the case studies from the previous assessment.
· A personal practice experience in which a sentinel event
occurred.
Instructions
The purpose of this assessment is to demonstrate your
understanding of and ability to analyze a root cause of a
specific safety concern in a health care setting. You will create
a plan to improve the safety of patients related to the concern
based on the results of your analysis, using the literature and
professional best practices as well as the existing resources at
your chosen health care setting to provide a rationale for your
plan.
Use the Root-Cause Analysis and Improvement Plan Template
[DOCX] to help you to stay organized and concise. This will
guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following,
which corresponds to the grading criteria in the scoring guide.
Please study the scoring guide carefully so you understand what
is needed for a distinguished score.
· Apply evidence-based and best-practice strategies to address
the safety issue or sentinel event.

· Identify organizational resources that could be leveraged to
improve your plan.
APA style.
Example Assessment: You may use the following to give you an
idea of what a Proficient or higher rating on the scoring guide
would look like:
· Assessment 2 Example [PDF].
Additional Requirements
· Length of submission: Use the provided Root-Cause Analysis
and Improvement Plan template to create a 4–6 page root cause
analysis and safety improvement plan. A title page is not
required but you must include a reference list as per the
template.
· Number of references: Cite a minimum of 3 sources of
scholarly or professional evidence that support your findings
and considerations. Resources should be no more than 5 years
old.
· APA formatting: Format references and citations according to
current APA style.
Note: Your instructor may also use the Writing Feedback Tool
to provide feedback on your writing. In the tool, click the
linked resources for helpful writing information.
Portfolio Prompt: Remember to save the final assessment to
your ePortfolio so that you may refer to it as you complete the
final Capstone course.

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