Root-Cause Analysis and Safety Improvement Plan
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.
1
, Understanding What Happened
1. What happened?: Begin by Michele, a 65-year old woman is admitted for chest discomfort at our facility. The patient has a
understanding the sequence of history of hypertension, and is diagnosed with pulmonary embolism. After diagnostic and
events leading up to the sentinel laboratory diagnostic, she is prescribed heparin to be delivered using a weight-based heparin
event. Gather detailed information infusion protocol. However, when receiving the infusion she begins suffering from headaches
about the incident, including and severe nose bleeds. The nurse in-charge reassess the dose of the heparin, and discovers
the timeline, people involved, that the dose is higher than required. She informs the physician in-charge, who orders a brain
and context. scan. Laboratory diagnostics are also conducted and show that the patient has more than 250
o Who did the seconds of partial thromboplatin time. The nurse immediately transfers the patient to the
problem/event affect, and intensive care unit for observation.
how?
2. Why did it happen?: A root-cause analysis show that there are several problems that contributed to the error.
o Human Factors: Investigate Human factors, including communication breakdown, and failure to double check the
whether communication concentration of the heparin contributed to the problem. First, the error occurred after a shift
breakdowns, staff fatigue, handoff. During the handoff, the nurses did not include information about the concentration
or lack of and rate of infusion, thus contributing to the error. Secondly, the two nurses who initiated the
training contributed. heparin infusion did not double check the rate and conception of the drug. The other
o System Factors: contributing factor is equipment failures. The infusion pump was manually programmed, and
Examine workflow was not integrated into electronic health records. Moreover, the pump had is scan error
processes, equipment overridden. That meant that the pump was misprogrammed, and could not detect errors
failures, rerated to wrong dosage and rate of infusion. At the organizational level, there
and environmental factors. Were failures in both policy and procedures. The nurses did not follow the required hospital
o Organizational Culture: policy that requires nurses to use the five rights of medication, and conduct double checks to
Assess if there are cultural ensure that those rights are adhered to during medication administration procedures.
issues, lack of safety
culture, or inadequate
leadership support.
o Society/Culture: What role
might cultural assumptions
or backgrounds play?
3. Was there a deviation from The nurses failed to adhere to the five rights of medication administration , right patient, right
2
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.
1
, Understanding What Happened
1. What happened?: Begin by Michele, a 65-year old woman is admitted for chest discomfort at our facility. The patient has a
understanding the sequence of history of hypertension, and is diagnosed with pulmonary embolism. After diagnostic and
events leading up to the sentinel laboratory diagnostic, she is prescribed heparin to be delivered using a weight-based heparin
event. Gather detailed information infusion protocol. However, when receiving the infusion she begins suffering from headaches
about the incident, including and severe nose bleeds. The nurse in-charge reassess the dose of the heparin, and discovers
the timeline, people involved, that the dose is higher than required. She informs the physician in-charge, who orders a brain
and context. scan. Laboratory diagnostics are also conducted and show that the patient has more than 250
o Who did the seconds of partial thromboplatin time. The nurse immediately transfers the patient to the
problem/event affect, and intensive care unit for observation.
how?
2. Why did it happen?: A root-cause analysis show that there are several problems that contributed to the error.
o Human Factors: Investigate Human factors, including communication breakdown, and failure to double check the
whether communication concentration of the heparin contributed to the problem. First, the error occurred after a shift
breakdowns, staff fatigue, handoff. During the handoff, the nurses did not include information about the concentration
or lack of and rate of infusion, thus contributing to the error. Secondly, the two nurses who initiated the
training contributed. heparin infusion did not double check the rate and conception of the drug. The other
o System Factors: contributing factor is equipment failures. The infusion pump was manually programmed, and
Examine workflow was not integrated into electronic health records. Moreover, the pump had is scan error
processes, equipment overridden. That meant that the pump was misprogrammed, and could not detect errors
failures, rerated to wrong dosage and rate of infusion. At the organizational level, there
and environmental factors. Were failures in both policy and procedures. The nurses did not follow the required hospital
o Organizational Culture: policy that requires nurses to use the five rights of medication, and conduct double checks to
Assess if there are cultural ensure that those rights are adhered to during medication administration procedures.
issues, lack of safety
culture, or inadequate
leadership support.
o Society/Culture: What role
might cultural assumptions
or backgrounds play?
3. Was there a deviation from The nurses failed to adhere to the five rights of medication administration , right patient, right
2
