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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

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