Root-Cause Analysis and Safety Improvement Plan

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.
  • One of the case studies from the previous assessment.
  • A personal practice experience in which a sentinel event occurred.

Root-Cause Analysis

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Analyze the root cause of a patient safety issue or a specific sentinel event in an organization. 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:

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·      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?

o   Were there any steps that were not taken or did not happen as intended?

·      What environmental factors (controllable and uncontrollable) 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

Create a feasible, evidence-based safety improvement plan. 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.

o   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 organizational resources that could be leveraged to improve your plan.Identify existing organizational personnel and/or resources that would help improve the implementation or outcomes of the plan.

o   A brief note on resources that may need to be obtained for the success of the plan.

o   Consider what existing resources may be leveraged enhance the improvement plan?

·  Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4 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.

o   ·  APA formatting: Format references and citations according to current APA style.

o   References

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