Develop a 4-to 6-page paper detailing a Root Cause Analysis and an accompanying Safety Improvement Plan based on a provided clinical scenario involving a medication administration error. You must utilize an established RCA tool, such as the fishbo

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NURS 4020: Quality Improvement and Patient Safety

Assessment Task 2: Root Cause Analysis and Safety Improvement Plan

Course Code: NURS 4020

Assessment Type: Written Report / Case Study Analysis

Word Length: A 4-to 6-page paper

Assignment Context

Clinical practice environments demand rigorous evaluation of adverse outcomes to prevent future occurrences. The Root Cause Analysis (RCA) framework allows healthcare professionals to systematically trace sentinel events back to their origin. Students often encounter challenges distinguishing between individual human error and systemic procedural failures. Applying an evidence-based quality improvement model transforms reactive nursing practice into proactive patient safety management. Internalizing this evaluative process is a standard requirement for leadership roles in clinical settings.

Task Description

Develop a 4-to 6-page paper detailing a Root Cause Analysis and an accompanying Safety Improvement Plan based on a provided clinical scenario involving a medication administration error. You must utilize an established RCA tool, such as the fishbone diagram or the “Five Whys” methodology, to dissect the contributing factors of the event. Formulate an evidence-based intervention strategy aimed at mitigating these specific systemic failures and outline a protocol for interdisciplinary implementation.

Assignment Requirements

• Identify the central issue in the clinical scenario and describe the sentinel event accurately without focusing solely on individual blame.
• Apply an RCA framework to categorize the human factors, environmental variables, and technological barriers that led to the medication error.
• Design a safety improvement plan featuring a specific, measurable intervention supported by current clinical guidelines.
• Outline the roles of interdisciplinary team members in executing and sustaining the proposed safety intervention.
• Integrate a minimum of four peer-reviewed nursing or medical journals published within the last five years.
• Format the manuscript, citations, and reference list according to APA 7th Edition guidelines, including title page and specific level headings.

Grading Rubric / Marking Criteria

Criterion	Exceeds Expectations (90-100%)	Meets Expectations (75-89%)	Needs Improvement (<75%)
Event Analysis & RCA Application	Expertly maps the sentinel event using a recognized RCA tool. Accurately isolates complex systemic factors over individual errors.	Adequately identifies causes of the event. The RCA tool is used correctly but lacks depth in connecting systemic variables.	Fails to use an RCA tool properly. Focuses inappropriately on punishing individual clinicians rather than systemic issues.
Safety Improvement Plan	Proposes a highly realistic, specific intervention tightly aligned with the RCA findings and current EBP standards.	Suggests a relevant intervention. Implementation details may lack specific measurement metrics or timeline structures.	The proposed plan is vague, untethered to the RCA findings, or lacks evidence-based support.
Interdisciplinary Collaboration	Clearly defines exact roles and communication strategies for multiple disciplines to sustain the safety initiative.	Mentions interdisciplinary involvement but provides superficial descriptions of specific team member responsibilities.	Ignores the role of interdisciplinary teams or isolates the intervention to a single nursing role.
Evidence & APA Formatting	Flawless APA 7th formatting. Integrates high-quality, current research seamlessly to justify clinical assertions.	Meets source requirements. Contains minor APA formatting errors or relies occasionally on weak source material.

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