Nursing Root Cause Analysis


A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome).
1. Discuss errors or hazards in care in the scenario.

B. Use change theory to develop an improvement plan to decrease the likelihood of a reoccurrence of the outcome of the scenario.

C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
• Identify the members of the interdisciplinary team who will be included in the RCA and FMEA.
1. Explain how you would test any interventions to improve care in a similar situation by changing the process of care.
2. Discuss pre-steps for preparing for the FMEA.
3. Describe the three steps of the FMEA: severity, occurrence, and detection.

Note: You are not expected to carry out the full FMEA, but you should describe each step and how you would go about it.

D. Discuss the key role nurses would play in improving the quality of care in this situation.

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