NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Root-Cause Analysis and Safety Improvement Plan Template
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?
A homeless adult patient with Type 2 diabetes was discharged from a community health
clinic after being treated for hyperglycemia. Standard discharge instructions were given,
and insulin therapy was prescribed. Within one week, the patient returned to the
emergency department with severe hypoglycemia due to incorrect insulin use and
inability to store medication safely because of lack of refrigeration and unstable living
conditions. The patient also complained of confusion regarding the dosage instructions.This event had an impact on the patient and led to an unnecessary hospital readmission
and acute metabolic instability.
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?
Human factors:
Patient had limited health literacy, and the nurse did not use a
teach-back approach to fully assess the patient’s understanding of the discharge
education.
System factors:
There was no structured screening of housing insecurity and
medication storage barriers included in the clinic discharge process.
Organizational culture:
Social determinants of health were not adequately
incorporated into the usual discharge planning process, which led to gaps in care.
Society/culture:
Stigma and assumptions related to homelessness may have
affected the extent of education offered NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
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.
Procedures and Policies:
In this case, standard discharge protocols for diabetes
management were only partially followed. The patient was prescribed insulin and given
general discharge directions, and the patient education and discharge safety protocols
were not followed to the proper extent in the clinic. In particular, the inclusion of SDH
within the discharge process was lacking, although the organization’s expectations were
that education be comprehensive and patient-centred.
Were there any steps that were not taken or did not happen as intended?
Yes.
Several key steps were either omitted or not completed as intended:• The teach-back method was not consistently used to confirm the patient’s
understanding of insulin administration
• There was no documented assessment of the patient’s ability to safely store
insulin, such as access to refrigeration or stable housing conditions.
• A formal screening for housing insecurity and related barriers (transportation,
food access, medication storage) was not performed.
• Interdisciplinary discharge coordination (involving social work and pharmacy)
was limited or absent, reducing the effectiveness of discharge planning.• No structured post-discharge follow-up plan within 48–72 hours was initiated to
assess medication adherence or understanding
Documentation:
A review of nursing notes and discharge documentation indicates that
patient education was recorded in a general manner (e.g., “diabetes education
provided”), but lacked specificity regarding teaching methods used, patient
comprehension, or validation of understanding. No evidence of assessor documentation
of teach-back, evidence of social needs assessment, or evidence of community
resources or case management contact at discharge. This led to inadequate
documentation of the education process and critical safety assessments, leading to poor
continuity of care and increased risk for medication-related harm.
Who was involved?
:
Staff
: Identify the
roles
of individuals directly involved in the event.
Supervisors and Managers
: Investigate
Staff:
Primary nurse carried out discharge teaching and documentation. Insulin therapy
was prescribed by the primary health care provider. The pharmacist dispensed the
medication and provided routine counselling. Barriers to self-administration included
limited health literacy and homelessness. There was no documentation of a social
worker or case manager being involved in discharge planning.
Supervisors and Managers:
Nurse supervisors & clinic leadership were indirectly
involved in the supervisory and management of the discharge process and staffing.
There was, however, a lack of evidence of active monitoring of the quality of discharge
education and structured interdisciplinary discharge planning for patients at high risk.
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.
Interdisciplinary Communication:
Yes. Communication was lacking between the
nurse, provider, pharmacy, and potential case management team. Key information about the patient’s homelessness and inability to store insulin was not effectively shared
across the care team, resulting in gaps in coordinated discharge planning
Patient-Provider Communication:
Yes. Discharge information was given, but
communication was not optimal. The teach-back method was not always employed, and
there was no verification of the patient’s knowledge of insulin use and storage.Therefore, the patient left the clinic without an understanding of how to use the
medication safely
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
.
Physical Environment:
The clinic environment did not have any systems or tools in
place to routinely address social determinants of health, including prompts for checking
for social determinants of health in the clinic workflow or access to resources for
medication storage supports. This reduced the capacity to optimally plan discharge for
homeless patients.
Staffing Levels:
Staffing was moderately constrained, causing time pressure during
discharge teaching. This probably limited the depth of education, the use of teach-back,
and coordination with other disciplines, such as social work or pharmacy, that are
important in high-risk patientsThe majority of staff had received training in diabetes management routine and
discharge education. However, there were competency gaps related to health literacy
assessment, trauma-informed care, and addressing social determinants of health in
clinical practice. Although nurses and providers were knowledgeable about insulin
therapy, they were not consistently skilled in using teach-back techniques or in adapting
education for patients experiencing homelessness. This prevented them from assessing
a patient’s understanding and adjusting instructions to fit the…
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.
GET HUMAN-WRITTEN PAPER HERE
What can be learned to prevent recurrence?
:
Lessons Learned
: Identify
systemic changes
,
training needs
, and
improvement opportunities
.
Quality Improvement
: Consider implementing
preventive measures
.
Lessons Learned:
This event highlights the need for safe discharge planning to go
beyond clinical care to include a comprehensive evaluation of social determinants of
health, with particular focus on housing stability. Marcus et al. (2024) note that for the
homeless patient, discharge planning that involves verification (teach-back), medication
storage capacity, and early engagement of interdisciplinary teams is necessary. It also
highlights a need for further education for staff on trauma-informed care and health
literacy strategies.
Quality Improvement:
All discharge protocols should include screening of housing
security, consistent implementation of teach-back, and social work and pharmaceutical
involvement in high-risk discharge protocols to prevent recurrence. Follow-up within
48-72 hours after discharge, and tailored medication support (e.g., simplified
prescribing/medication storage) will further decrease risk (Wallace et al., 2024). Staff
training and audit/feedback systems should also be implemented on a regular basis in
order to maintain compliance and enhance patient safety results
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
1
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
2
3
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 issue
s
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
1
2
3
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:
Instructions
This course has been completed and no further assessments may be submitted.
For this assessment, you must use the supplied template to conduct a root-cause analysis. The completed assessment will be the template, focusing on the specific safety concern identified in your previous assessment.
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Introduction
As patient safety concerns continue to be addressed in healthcare 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 healthcare 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.
Overview
Nursing practice is governed by healthcare 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.
For this assessment, use the specific safety concern identified in your previous assessment as the subject of a root-cause analysis and safety improvement plan NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
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 healthcare setting. You will create a plan to improve the safety of patients related to
the safety quality issue presented in your Assessment Supplement PDF in Assessment 1
. Based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen healthcare setting, provide a rationale for your plan.
Use the
Root-Cause Analysis and Safety Improvement Plan [DOCX]
template to complete the assessment.
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.
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 the safety issue or sentinel event.
Create a viable, evidence-based safety improvement plan.
Identify existing organizational resources that could be leveraged to improve your plan.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
Length of submission:
Use the provided template to create a root-cause analysis and safety improvement plan. There is no page limit. 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. Use the
BSN Nursing Program Library Guide
as needed.
APA formatting:
Format references and citations according to current APA style. See the
APA Module
.
Competencies Measured
By successfully completing this
assessment
, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event.
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a specific sentinel event or a patient safety issue in 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.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.
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Criterion 1
Analyze the root cause of a specific sentinel event or a patient safety issue in an organization.
Distinguished
Analyzes the root cause of a specific sentinel event or a patient safety issue in an organization. Notes the degree to which various causes contributed to the issue or event.
Proficient
Analyzes the root cause of a specific sentinel event or a patient safety issue in an organization.
Basic
Identifies the root cause of a specific sentinel event or a patient safety issue in an organization.
Non Performance
Does not identify the root cause of a specific sentinel event or a patient safety issue in an organization.
Criterion 2
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event.
Distinguished
Applies evidence-based and best-practice strategies to address a safety issue or sentinel event. Notes how the strategies will address the issue or event.
Proficient
Applies evidence-based and best-practice strategies to address a safety issue or sentinel event.
Basic
Describes evidence-based and best-practice strategies, but their relevance to the safety issue or sentinel event is unclear.
Non Performance
Does not apply evidence-based and best-practice strategies to address a safety issue or sentinel event.
Criterion 3
Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
Distinguished
Creates a feasible, evidence-based safety improvement plan. Refers explicitly to scholarly or professional resources to support the plan.
Proficient
Creates a feasible, evidence-based safety improvement plan.
Basic
Creates a safety improvement plan that lacks sufficient evidence or may not be feasible.
Non Performance
Does not create a safety improvement plan.
Criterion 4
Identify existing organizational resources that could be leveraged to improve a plan.
Distinguished
Identifies existing organizational resources that could be leveraged to improve a plan. Prioritizes resources according to potential impact.
Proficient
Identifies existing organizational resources that could be leveraged to improve a plan.
Basic
Identifies existing organizational resources, but their relevance to the plan is unclear.
Non Performance
Does not identify existing organizational resources that could be leveraged to improve a plan.
Criterion 5
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
Distinguished
Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar and punctuation, and word choice, and is free of spelling errors.
Proficient
Organizes content so ideas flow logically with smooth transitions; content contains few errors in grammar or punctuation, word choice, and spelling.
Basic
Organizes content with some logical flow and smooth transitions. Content contains errors in grammar or punctuation, word choice, and spelling.
Non Performance
Does not organize content for ideas. Content lacks logical flow and smooth transitions NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
Criterion 6
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Distinguished
Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.
Proficient
Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Basic
Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing.
Non Performance
Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly.
Resources
This course has been completed and no further assessments may be submitted.
Use the resources linked below to help complete this assessment.
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Reading
Root-Cause Analysis and Sentinel Events
With an increasing need of patient safety and quality improvement, root cause analysis is a necessity. Healthcare systems are implementing root cause analysis for the identification and reduction of errors. Root cause analysis uses a team approach with a focus on the entire system, not just the individual to acquire data on what happened and why.
In this reading list you’ll find resources as well as articles related to root-cause analysis. The last couple of resources also provide definitions, policies, and procedures related to sentinel events, which may help you to complete your assessment.
Assessment 2: Root-Cause Analysis and Sentinel Events
.
Evidence-Based Practice and Safety
The National Patient Safety Goals (NPSG) initiated by the Joint Commission works toward improving patient safety concerns while minimizing costs stemming from the issues. The NPSG offers ideas involving protocols and policies that may be implemented in various avenues of healthcare. Instituting a safety improvement plan is essential in the healthcare practice. A safety improvement plan is a simple and important plan to create actionable steps for improving safety performance.
Along with a link to the NPSG, you’ll find other information addressing evidence-based practice and safety in this reading list.
Assessment 2: Evidence-Based Practice and Safety
.
Program Resources
Capella Writing Center
Access the various resources in the Capella
Writing Center
to help you better understand and improve your writing.
APA Style and Format
Capella University follows the style and formatting guidelines in the
Publication Manual of the American Psychological Association,
known informally as the APA manual. Refer to the Writing Center’s
APA Module
for tips on proper use of APA style and format.
Capella University Library
The
BSN Nursing Program Library Guide
will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments.
BSN Practicum
Students enrolled in the BSN or RN-to-BSN degree program are required to complete direct practice hours.
Action Required:
In preparation for your practicum experience, you will want to review the
BSN Practicum
Campus page and begin the application process. Your site and preceptor must be approved before you start your practicum course(s). You will not be able to enroll in any specialization or practicum course until you have received your practicum application approval. The review process can take twelve weeks or longer, so to ensure your program progression is not delayed, you should start your application process as soon as possible. Submit all requirements as soon as possible for review and approval. NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan
