Root-Cause Analysis and Safety Improvement Plan

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 outcomes. Root-Cause Analysis and Safety Improvement Plan

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 engagement.

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 initiative.
    • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event.
    • Create a feasible, evidence-based safety improvement plan. Root-Cause Analysis and Safety Improvement Plan
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the root cause of a patient safety issue or a specific sentinel event within an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify existing organizational resources that could be leveraged to improve a plan.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Root-Cause Analysis and Safety Improvement Plan

Professional Context

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 improvements.


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.
  • The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.
  • One of the case studies from the previous assessment. Root-Cause Analysis and Safety Improvement Plan
  • A personal practice experience in which a sentinel event occurred.


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 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 your plan.

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. Root-Cause Analysis and Safety Improvement Plan

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.

According to Spath (2011), root-cause analysis is a methodical approach that aims to

discover the causes of adverse events and near misses for the purpose of identifying

preventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls in

geropsychiatric patients was conducted at an inpatient mental health unit. The paper describes

and analyzes falls and discusses evidence-based strategies to reduce falls and determine a

safety improvement plan based on the utilization of existing organizational resources to

address these falls. Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis of Falls in Geropsychiatric Inpatients


According to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control and

Prevention reported that falls were a leading cause of unintentional injury death in adults

aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead to

serious head trauma are common among older adults. Injury falls are serious and could lead

to fractures, head injury, and intracranial bleed. According to the National Quality Forum

(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope et

al., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate their

health conditions (Powell-Cope et al., 2014). Root-Cause Analysis and Safety Improvement Plan

Considering the adverse implications of falls in such patients, a root-cause analysis

was conducted on the 20 cases of falls reported over a period of one year at a geropsychiatric

inpatient facility. The aim of the analysis was to understand the causes of falls in

geropsychiatric patients at the unit. The analysis was conducted by a team of five experts

including clinicians, supervisors, and quality improvement personnel. The cases reported had

been registered by a team of nurses who collated the data related to the falls. All the falls

were described as cases of slipping or tripping, and patients mostly sustained injuries

involving pain, mild swelling, and abrasions, with only two of the cases involving minor


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fractures. It was also observed that all the falls occurred near the beds of patients and during

the evening or night shifts when nursing teams were more likely to be understaffed. Root-Cause Analysis and Safety Improvement Plan

Geropsychiatric patients are known to be susceptible to falls under the influence of

drugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in blood

pressure within three minutes of standing), ataxia (lack of voluntary muscular control caused

by injury to the central nervous system), and extrapyramidal slowing (impaired motor

functions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,

hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to these

kinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of falls

and noted that in over 50% of the cases, patients had been ambulating under the influence of

drugs. It was also noted that 80% of the patients who fell while ambulating under the

influence of drugs had been prescribed zolpidem. Root-Cause Analysis and Safety Improvement Plan

At least 40% of the falls could be attributed to generalized weakness, disorientation,

and difficulty with mobility. Fall and injury risks are often complicated by behavioral

circumstances such as anger, anxiety, hyperarousal, and the inability to call for help or to

remember to call for help. Physical conditions that occur with substance abuse (such as

malnourishment and dehydration) co-exist with psychiatric disability and cause further

complications (Powell-Cope et al., 2014).

Another factor that plays a role in patient safety is infrastructure in hospitals. This was

particularly noteworthy as all the falls studied had occurred when patients ambulated near

their beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskid

footwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,

2014) Root-Cause Analysis and Safety Improvement Plan

Also check: Global Health Comparison Matrix

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