WGU C489 Task 1: Organizational Systems and Quality Leadership – Root Cause Analysis (RCA)

Course Overview

Course: C489 – Organizational Systems and Quality Leadership

Assessment: Task 1: Root Cause Analysis and Process Improvement

Year: 2025

Professor’s Perspective: Why This Matters

Hello everyone. You are about to tackle one of the most practical assignments in your nursing program: the Root Cause Analysis (RCA). In the real world, when a sentinel event occurs (like the medication error in the provided case study), our instinct is often to blame the individual. However, C489 asks you to put on your “systems thinking” cap. We aren’t looking for who made the mistake; we are looking for why the system allowed the mistake to happen. This assessment requires you to dissect a scenario, map out the failure, and propose a data-driven solution. Focus heavily on the “Change Theory” section—this is where many students lose points because they simply list a theory without explaining how they will apply it to change staff behavior.

Assessment Brief & Instructions

Case Study Analysis

Read the provided scenario (commonly referring to “Mr. B” or a similar patient safety event involving a medication error or fall). You must base your entire analysis on this specific event.

A. Root Cause Analysis (RCA)

Conduct an RCA to determine the underlying factors contributing to the adverse event.

1. RCA Explanation: Explain what a Root Cause Analysis is and why it is used in healthcare settings to improve safety.
2. Causal Factors: Identify and discuss two specific causal factors from the scenario that contributed to the error. (Think: Was it staffing? Technology? Communication? Policy?)
3. Fishbone Diagram (Ishikawa): Although you cannot draw in the essay, describe the components you would include in a Fishbone diagram for this event.
   • Identify the main problem (the head of the fish).
   • Identify four categories of causes (e.g., People, Methods, Equipment, Environment).

B. Improvement Plan

Propose a process improvement plan to prevent this error from recurring.

1. Proposed Intervention: distinct from the current process, describe a new evidence-based intervention or process change.
2. Change Theory: Select a change theory (e.g., Lewin’s Change Model or Kotter’s 8 Steps).
   • Explain the theory.
   • Application: Detail exactly how you will use this theory to implement your proposed intervention. (e.g., “In the ‘Unfreezing’ stage, I will…”)
3. Interdisciplinary Team: Identify three distinct interdisciplinary team members (roles, not names) required for this team. Explain why each is necessary for the success of this specific plan.

C. Evaluation (PDSA Cycle)

Discuss how you will evaluate the effectiveness of your improvement plan using the Plan-Do-Study-Act (PDSA) cycle.

• Plan: What are you planning to test or implement?
• Do: How will you carry out the test?
• Study: What data will you collect to measure success? (Be specific—e.g., “medication error rates over 3 months”).
• Act: Based on the data, what will determine if you adopt, adapt, or abandon the plan?

D. General Guidelines

• Length: Typically 4–6 pages (excluding references and title page).
• Format: APA Style (7th Edition).
• Sources: Include in-text citations and a reference list.

“To address the medication administration error observed in Mr. B’s case, the ‘Unfreezing’ stage of Lewin’s Change Model will be pivotal. During this phase, the nurse leader must demonstrate to the staff that the current reliance on memory for medication verification is unsafe and unsustainable. By presenting data on recent near-misses and highlighting the emotional toll of the recent sentinel event, the leader creates a sense of urgency. This disrupts the status quo, reducing resistance and preparing the team to accept the new barcode scanning protocol as a necessary safety evolution rather than a bureaucratic hurdle.”

Learning Resources

• Barrow, J.M., Annamaraju, P. and Toney-Butler, T.J. (2024) ‘Change management’, in StatPearls. Treasure Island (FL): StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459380/.
• Hibbert, P.D. et al. (2020) ‘Root cause analysis of patient safety incidents in primary care: A systematic review’, Family Practice, 37(4), pp. 437–450. Available at: https://doi.org/10.1093/fampra/cmaa008.
• Kellogg, K.M. et al. (2021) ‘Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety?’, BMJ Quality & Safety, 26(5), pp. 381–387. Available at: https://doi.org/10.1136/bmjqs-2016-005991.
• Peerally, M.F. et al. (2023) ‘The problems with root cause analysis’, BMJ Quality & Safety, 26(5), pp. 417–422. Available at: https://doi.org/10.1136/bmjqs-2016-005511.
• Wei, H. et al. (2022) ‘The state of the science of nurse work environments in the United States: A systematic review’, International Journal of Nursing Sciences, 5(3), pp. 287–300. Available at: https://doi.org/10.1016/j.ijnss.2018.04.010.