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Discussion Post 3: Root Cause Analysis

Describe an experience with Root Cause Analysis that you had in practice or your clinical practicum using a fishbone diagram or 5 Whys method. What was the adverse event? What was your role? As a nurse leader, how would you prevent the adverse event (or near miss) from happening again?

Provide at least two references from the required reading and any additional references needed.

Root cause analysis (RCA) is a structured investigative methodology aimed at identifying and correcting the underlying system-level causes of adverse events (Spath & DeVane, 2022). During my clinical practice, I participated in an RCA following a serious adverse event involving a confused patient who eloped from their home, found by police several hours later, transferred to our inpatient unit, and subsequently passed away. Although uncommon, sentinel events such as this often expose serious vulnerabilities in clinical practices and processes, requiring prompt and comprehensive investigation to prevent recurrence (Huang et al., 2025).

The adverse event resulted in delayed medical intervention and poor patient outcomes. My organization utilized the Five Whys method to examine the contributing factors leading up to the event. The Five Whys technique enables improvement teams to systematically explore problems by repeatedly asking why, allowing for comprehensive examination of the situation and identification of underlying contributing factors (Spath & DeVane, 2022).

Using the Five Whys approach, the following contributing factors were identified:

1. Why did the patient elope?
2. The patient was confused and left the home unsupervised.
3. Why was the patient unsupervised?
4. Caregiver supervision and safety monitoring were inconsistent despite ongoing education provided by staff and the initiation of a behavior contract. An Adult Protective Services (APS) report was filed but was determined to be unsubstantiated.
5. Why was supervision inconsistent?
6. The patients sister, who served as the health care surrogate, did not implement recommended interventions despite staff education and encouragement.
7. Why was the elopement risk not adequately mitigated?
8. Although standardized risk assessment tools and escalation protocols were used by staff, there was insufficient support from APS and family members to ensure patient safety.
9. Why were safety protocols not consistently effective?
10. Gaps existed between staff education and the actions communicated by the family to the care team regarding planned safety measures.

At the time of the event, I served as the Nurse Director overseeing the nurse responsible for the patients care. My role included supporting staff throughout the RCA process, ensuring transparent reporting, and communicating findings to senior leadership, who subsequently reported to the Chief Clinical Operations Officer (CCOO). I also participated in reviewing system-level failures and contributing factors rather than focusing on individual faults.

As a nurse leader, preventing a similar adverse event requires a proactive, system-based approach. Key prevention strategies include standardized cognitive and elopement risk assessments for patients receiving home-based care; clear escalation and communication protocols for high-risk patients; enhanced staff education and competency validation related to caring for confused patients in non-inpatient settings; caregiver education and support with explicit supervision expectations; and leadership oversight through auditing and review of near-miss events.

By addressing these root causes, nurse leaders can help create safer systems that reduce the likelihood of patient elopement and improve outcomes for vulnerable populations. To achieve their full potential, RCAs must be grounded in a psychologically safe and transparent framework that promotes open reporting and collective learning, yields specific and actionable findings, and facilitates meaningful, sustainable improvements in patient safety and organizational safety culture (Behrhorst et al., 2025).

References

Behrhorst J, Gale B, Van CM. (2025). The Evolution of Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.

Huang, L.-L., Jiang, Y.-H., Yang, J.-H., Hong, W.-W., Chen, H.-F., & Hu, W.-W. (2025). Experience of nurse-guided root cause analysis after a sentinel event: A qualitative study. BMC Nursing, 24(1). https://doi.org/10.1186/s12912-025-02787-6

Spath, P.L., & DeVane, K. A. (2022). Introduction to Healthcare Quality Management (4th ed.). Health Administration Press. https://reader2.yuzu.com/books/978164055413

Create a pharmaceutical treatment regimen for each of the following.

• 50-year-old Russian born female diagnosed with atrial fibrillation. Recent increase in palpitations
• 62-year-old Black male diagnosed with hypertension. Baseline today 160/100
• 83-year-old White male diagnosed with Heart Failure and a history of 2 MIs. Stable at present. Primary regimen is managed via cardiology. You support oversight of HTN monitoring and provide other primary care.
• The patient specific details are yours to develop and consider to support your choices.
• You will have to assume a current regiment, and then make changes/additions.
• The non-prescription medication if any, AND the prescription details must be present.
• For each the drug name, dose, route, frequency of administration and if prescribed, the quantity to dispense must be present
• Include the drug class details
• Justify your reasoning
• What labs will you monitor? Why?
• Consider aspects of determinants of health in your response such as individual behavior and genetics.

Please complete. Instructions uploaded. You would be completing Part 2. I have also uploaded an example, which includes Parts 1 and 2. Please make sure you complete Part 2.

1. Discuss the significance of service learning in nursing.
2. Discuss the nurses role in health promotion services to the community.
3. Reflect on personal experience with service learning in nursing practice.
4. Explore how service learning might help to address the nursing shortage.
5. All submissions should have a title page and a reference page.
6. Utilize a minimum of three scholarly resources.

I need you to write a nursing paper describing how each of ethical principles should be addressed in multicultural setting. No plag and AI. Deadline is February, 15th. Length – 2,000-2,200 words, please do not exceed the word count.

Students are required to submit reflective journal entries at specific points throughout the course. These reflective narratives help students identify important learning events that happen throughout the course and the practicum. Write a reflective journal (250-500 words) to outline how your experience at your practicum site related to the following reflective questions: Based on your practicum experience, describe leadership behaviors you have observed from your preceptor and from other leaders at the practicum site. Discuss leadership behaviors you have demonstrated during your practicum experience to communicate a consistent image of the nurse as a leader. Reflect on the leadership skills you have gained during your practicum experience. Describe two leadership areas in which you would like to further improve. Discuss one way in which you will work to improve in these areas. While APA style is not required for the body of this assignment, solid academic writing is expected. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Assignment #1: Create a Nursing Care Plan for a Patient at Risk for Suicide Instructions: Assignment Overview: For this assignment, you will develop a comprehensive Nursing Care Plan for a patient at risk for suicide. This care plan should address the patients physical, emotional, and psychological needs, focusing on interventions that reduce the risk of self-harm and promote mental well-being. Care Plan Components: Patient Assessment: Conduct a thorough assessment of the patients mental health status. Include signs and symptoms of suicidal ideation, emotional distress, and any contributing factors such as previous attempts or family history of mental health issues. Refer to Table 25.2 (Chapter 25, Page 477) to guide your assessment of symptoms of suicidal ideation. Nursing Diagnosis: Identify appropriate nursing diagnoses for a patient at risk for suicide. These may include: Risk for Suicide Hopelessness Ineffective Coping Risk for Self-Directed Violence Goals and Outcomes: Set clear, measurable goals for the patients care. These goals may include: Preventing self-harm Establishing a safety plan Improving emotional stability and coping mechanisms Reducing feelings of hopelessness or isolation Nursing Interventions: Develop specific nursing interventions aimed at reducing the risk of suicide. These may include: Ensuring the patient is in a safe environment (e.g., removing dangerous objects, implementing constant observation if necessary) Establishing a trusting relationship with the patient through therapeutic communication Collaborating with mental health professionals to develop a treatment plan Educating the patient and family members about warning signs and available resources Providing crisis intervention or referral to mental health services Evaluation: Discuss how you will evaluate the effectiveness of the nursing care plan. Include specific indicators such as improved emotional well-being, the patients adherence to the safety plan, and reduced suicidal ideation. Writing Guidelines: Format: Submit your care plan in APA format, including a title page, in-text citations, and a reference list if applicable. Length: The care plan should be 2-3 pages in length.

The National Committee for Quality Assurance (NCQA) ensures the quality of client care using defined standards.

is a performance measurement tool millions of health insurance plans use. HEDIS includes six domains of care:

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Risk Adjusted Utilization
• Health Plan Descriptive Information
• Measures Collected Using Electronic Clinical Data Systems

Include the following sections (detailed criteria listed below and in the grading rubric).

1. Identification of the Selected Measure
2. Identify the selected performance measure and provide the full description of the measure.
3. Analyze the selected measure for clinical significance and evidence base considering both short term and long-term clinical significance.
4. Describe practical implications for clinical nurse practitioner practice.
5. Provide support from at least one scholarly source as defined by the NP program expectations.
6. Implementation Planning
7. Develop a detailed quality improvement plan for implementing the selected measure in your current or future practice, including:
8. Specific strategies for client education
9. Clinical workflow integration roles and responsibilities
10. Documentation roles and responsibilities
11. Provide support from at least one scholarly source as defined by the NP program expectations.
12. Measurement
13. Identify a tool or data collection technique to measure the outcomes of implementing the selected measure. Provide a detailed description of pre- and post-implementation measurement describing roles and responsibilities.
14. Describe how the tool can be successfully implemented in NP clinical practice.
15. Provide support from at least one scholarly source as defined by the NP program expectations.
16. Application to Practice
17. Discuss in detail how the interventions can improve client outcomes.
18. Discuss in detail how the interventions can improve cost savings for the practice in both the short-term and the long-term.
19. Discuss in detail how the interventions can improve client ratings (an NPs patient scorecard).
20. Provide support from at least one scholarly source as outlined in the NP programs expectations.
21. Reflection
22. Reflect on the importance of using NCQA HEDIS measures in NP clinical practice.
23. Identify two key takeaways to apply to your current or future practice.

The selected NCQA HEDIS performance measure is Hospitalization Within 30 Days of Skilled Nursing Facility (SNF) Discharge.

use 3 scholarly articles within the last 5 years