Root-Cause Analysis and Safety Improvement Plan
Assessment 2 Instructions:
Root-Cause Analysis and
Safety Improvement Plan
For this assessment, you will use a supplied template to conduct a root-cause
analysis of a quality or safety issue in a health care setting of your choice and
outline a plan to address the issue.
As patient safety concerns continue to be addressed in the health care settings,
nurses can play an active role in implementing safety improvement measures
and plans. Often root-cause analyses are conducted and safety improvement
plans are created to address sentinel or adverse events such as medication
errors, patient falls, wrong-site surgery events, and hospital-acquired infections.
Performing a root-cause analysis offers a systematic approach for identifying
causes of problems, including process and system-check failures. Once the
causes of failures have been determined, a safety improvement plan can be
developed to prevent recurrences. The baccalaureate nurse's role as a leader is
to create safety improvement plans as well as disseminate vital information to
staff nurses and other health care professionals to protect patients and improve
As you prepare for this assessment, it would be an excellent choice to complete
the Quality and Safety Improvement Plan Knowledge Base activity and to review
the various assessment resources, all of which will help you build your
knowledge of key concepts and terms related to quality and safety improvement.
The terms and concepts will be helpful as you prepare your Root-Cause Analysis
and Safety Improvement Plan. Activities are not graded and demonstrate course
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your
proficiency in the following course competencies and assessment criteria:
Competency 1: Analyze the elements of a successful quality improvement
o Apply evidence-based and best-practice strategies to address a
safety issue or sentinel event pertaining to medication
o Create a viable, evidence-based safety improvement plan for safe
Competency 2: Analyze factors that lead to patient safety risks.
o Analyze the root cause of a patient safety issue or a specific sentinel
event pertaining to medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient
o Identify existing organizational resources that could be leveraged to
improve a safety improvement plan for safe medication
Competency 5: Apply professional, scholarly, evidence-based strategies to
communicate in a manner that supports safe and effective patient care.
o Communicate in writing that is clear, logical, and professional, with
correct grammar and spelling, using current APA style.
Nursing practice is governed by health care policies and procedures as well as
state and national regulations developed to prevent problems. It is critical for
nurses to participate in gathering and analyzing data to determine causes of
patient safety issues, in solving problems, and in implementing quality
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
pertaining to medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel
event occurred surrounding an issue or concern with medication
The purpose of this assessment is to demonstrate your understanding of and
ability to analyze a root cause of a specific safety concern in a health care
setting. You will create a plan to improve the safety of patients related to the
concern of medication administration safety based on the results of your
analysis, using the literature and professional best practices as well as the
existing resources at your chosen health care setting to provide a rationale for
Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help
you to stay organized and concise. This will guide you step-by-step through the
root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds
to the grading criteria in the scoring guide. Please study the scoring guide
carefully so you understand; what is needed for a distinguished score.
Analyze the root cause of a patient safety issue or a specific sentinel event
pertaining to medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety
issue or sentinel event pertaining to medication administration.
Create a feasible, evidence-based safety improvement plan for safe
Identify organizational resources that could be leveraged to improve your
plan for safe medication administration.
Communicate in writing that is clear, logical, and professional, with correct
grammar and spelling, using current APA style.
Example Assessment: You may use the following to give you an idea of what a
Proficient or higher rating on the scoring guide would look like but keep in mind
that your Assessment 2 will focus on safe medication administration.
Length of submission: Use the provided Root-Cause Analysis and
Improvement Plan template to create a 4-6 page root cause analysis and
safety improvement plan pertaining to medication administration.
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.
APA formatting: Format references and citations according to current APA