{"id":10996,"date":"2025-10-03T12:37:32","date_gmt":"2025-10-03T12:37:32","guid":{"rendered":"https:\/\/www.essaybishops.com\/au\/?p=10996"},"modified":"2025-10-03T12:37:33","modified_gmt":"2025-10-03T12:37:33","slug":"analyzing-root-causes-of-patient-safety-events","status":"publish","type":"post","link":"https:\/\/www.colapapers.com\/essays\/analyzing-root-causes-of-patient-safety-events\/","title":{"rendered":"Root-Cause Analysis and Evidence-Based Safety Improvement Plan for Healthcare-Associated Medication Errors in Acute Care Settings"},"content":{"rendered":"<h3>References<\/h3>\n<ul>\n<li class=\"whitespace-normal break-words\"><strong>Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., &amp; Fairbanks, R. J. (2020).<\/strong> Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? <em>BMJ Quality &amp; Safety, 29<\/em>(11), 1991-1998. <a class=\"underline\" href=\"https:\/\/doi.org\/10.1136\/bmjqs-2019-010186\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1136\/bmjqs-2019-010186<\/a><\/li>\n<li class=\"whitespace-normal break-words\"><strong>Peerally, M. F., Carr, S., Waring, J., &amp; Dixon-Woods, M. (2022).<\/strong> The problem with root cause analysis: A systematic review. <em>BMJ Quality &amp; Safety, 31<\/em>(8), 589-598. <a class=\"underline\" href=\"https:\/\/doi.org\/10.1136\/bmjqs-2021-013726\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1136\/bmjqs-2021-013726<\/a><\/li>\n<li class=\"whitespace-normal break-words\"><strong>Hibbert, P. D., Molloy, C. J., Hooper, T. D., Wiles, L. K., Runciman, W. B., Lachman, P., Muething, S. E., &amp; Braithwaite, J. (2021).<\/strong> The application of the Global Trigger Tool: A systematic review. <em>International Journal for Quality in Health Care, 33<\/em>(1), 1-19. <a class=\"underline\" href=\"https:\/\/doi.org\/10.1093\/intqhc\/mzaa115\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1093\/intqhc\/mzaa115<\/a><\/li>\n<li class=\"whitespace-normal break-words\"><strong>Vincent, C., &amp; Amalberti, R. (2023).<\/strong> Creating a culture of safety in healthcare: Current challenges and future opportunities. <em>BMJ Quality &amp; Safety, 32<\/em>(1), 1-4. <a class=\"underline\" href=\"https:\/\/doi.org\/10.1136\/bmjqs-2022-015527\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1136\/bmjqs-2022-015527<\/a><\/li>\n<li class=\"whitespace-normal break-words\"><strong>Rodziewicz, T. L., Houseman, B., &amp; Hipskind, J. E. (2024).<\/strong> Medical error reduction and prevention. In <em>StatPearls<\/em>. StatPearls Publishing. <a class=\"underline\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK499956\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK499956\/<\/a><\/li>\n<\/ul>\n<h1 class=\"text-2xl font-bold mt-1 text-text-100\">NURS4035: Improving Quality of Care and Patient Safety<\/h1>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Assessment 2: Root-Cause Analysis and Safety Improvement Plan<\/h2>\n<p class=\"whitespace-normal break-words\"><strong>Course:<\/strong> NURS4035 &#8211; Improving Quality of Care and Patient Safety<br \/>\n<strong>Program:<\/strong> Bachelor of Science in Nursing (BSN)<br \/>\n<strong>School:<\/strong> School of Nursing and Health Sciences, Capella University<br \/>\n<strong>Assessment Type:<\/strong> Written Analysis and Safety Plan<br \/>\n<strong>Estimated Time to Complete:<\/strong> 10-15 hours<\/p>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Assessment Overview<\/h2>\n<p class=\"whitespace-normal break-words\">Patient safety incidents and sentinel events represent critical opportunities for healthcare organizations to learn, improve systems, and prevent future harm. This assessment challenges you to conduct a comprehensive root-cause analysis (RCA) of a safety concern or sentinel event within a healthcare setting and develop an evidence-based safety improvement plan to address the identified root causes.<\/p>\n<p class=\"whitespace-normal break-words\">You will demonstrate your understanding of systematic analysis techniques, evidence-based quality improvement strategies, and the development of actionable safety improvement plans. This assessment emphasizes the importance of moving beyond individual blame to identify systemic factors that contribute to patient safety events.<\/p>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Assessment Instructions<\/h2>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Scenario<\/h3>\n<p class=\"whitespace-normal break-words\">You are a nurse leader or quality improvement team member at a healthcare organization that has experienced a patient safety incident or sentinel event. Your leadership has tasked you with conducting a thorough root-cause analysis and developing a comprehensive safety improvement plan to prevent similar occurrences in the future.<\/p>\n<p class=\"whitespace-normal break-words\"><strong>Select ONE of the following safety concerns or sentinel events for your analysis:<\/strong><\/p>\n<ol class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-decimal space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>Medication Error<\/strong> &#8211; Wrong medication, wrong dose, wrong route, or wrong patient<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Healthcare-Associated Infection (HAI)<\/strong> &#8211; CAUTI, CLABSI, surgical site infection, or C. difficile<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Patient Fall with Injury<\/strong> &#8211; Fall resulting in fracture, head trauma, or other serious injury<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Pressure Injury Development<\/strong> &#8211; Stage III or IV pressure injury acquired during hospitalization<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Delayed or Missed Diagnosis<\/strong> &#8211; Failure to recognize or act on critical findings<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Surgical Error<\/strong> &#8211; Wrong-site surgery, retained foreign object, or procedural complication<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Communication Failure<\/strong> &#8211; Handoff error, critical test result not communicated, or care coordination breakdown<\/li>\n<\/ol>\n<p class=\"whitespace-normal break-words\">You may draw from your own clinical experience, use a hypothetical but realistic scenario, or research a published case study. However, do NOT use actual patient names or identifying information to maintain confidentiality and HIPAA compliance.<\/p>\n<hr class=\"border-border-300 my-2\" \/>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Part 1: Root-Cause Analysis (3-4 pages)<\/h3>\n<p class=\"whitespace-normal break-words\">Conduct a systematic root-cause analysis of your selected safety concern or sentinel event. Your analysis should address the following:<\/p>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">A. Event Description and Context (1 page)<\/h4>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Provide a detailed description of the safety incident or sentinel event<\/li>\n<li class=\"whitespace-normal break-words\">Describe the healthcare setting, patient population, and relevant clinical context<\/li>\n<li class=\"whitespace-normal break-words\">Outline the sequence of events leading up to and following the incident<\/li>\n<li class=\"whitespace-normal break-words\">Identify who was affected and the extent of harm or potential harm<\/li>\n<li class=\"whitespace-normal break-words\">Include the immediate response to the event<\/li>\n<\/ul>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">B. Systematic Analysis of Contributing Factors (2-3 pages)<\/h4>\n<p class=\"whitespace-normal break-words\">Use a structured approach (such as the Five Whys, Fishbone Diagram, or Systems Analysis) to identify contributing factors across multiple categories:<\/p>\n<p class=\"whitespace-normal break-words\"><strong>Human Factors:<\/strong><\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Communication breakdowns (handoffs, team communication, documentation)<\/li>\n<li class=\"whitespace-normal break-words\">Training and competency gaps<\/li>\n<li class=\"whitespace-normal break-words\">Fatigue, workload, or staffing issues<\/li>\n<li class=\"whitespace-normal break-words\">Individual knowledge or skill deficits<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\"><strong>System Factors:<\/strong><\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Workflow processes and procedures<\/li>\n<li class=\"whitespace-normal break-words\">Technology and equipment failures or limitations<\/li>\n<li class=\"whitespace-normal break-words\">Physical environment and facility design<\/li>\n<li class=\"whitespace-normal break-words\">Resource availability<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\"><strong>Organizational Factors:<\/strong><\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Policies, protocols, and procedures<\/li>\n<li class=\"whitespace-normal break-words\">Safety culture and leadership support<\/li>\n<li class=\"whitespace-normal break-words\">Quality monitoring and surveillance systems<\/li>\n<li class=\"whitespace-normal break-words\">Organizational priorities and resource allocation<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\"><strong>External Factors:<\/strong><\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Regulatory requirements<\/li>\n<li class=\"whitespace-normal break-words\">Industry standards and best practices<\/li>\n<li class=\"whitespace-normal break-words\">Patient and family factors<\/li>\n<li class=\"whitespace-normal break-words\">Sociocultural considerations<\/li>\n<\/ul>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">C. Root Cause Identification<\/h4>\n<p class=\"whitespace-normal break-words\">Based on your analysis, explicitly identify 2-3 root causes that fundamentally contributed to the safety event. Categorize each root cause using the following framework:<\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>HF-C<\/strong>: Human Factor &#8211; Communication<\/li>\n<li class=\"whitespace-normal break-words\"><strong>HF-T<\/strong>: Human Factor &#8211; Training\/Competency<\/li>\n<li class=\"whitespace-normal break-words\"><strong>HF-F\/S<\/strong>: Human Factor &#8211; Fatigue\/Scheduling\/Staffing<\/li>\n<li class=\"whitespace-normal break-words\"><strong>E<\/strong>: Environment\/Equipment<\/li>\n<li class=\"whitespace-normal break-words\"><strong>R<\/strong>: Rules\/Policies\/Procedures<\/li>\n<li class=\"whitespace-normal break-words\"><strong>B<\/strong>: Barriers (to implementation or compliance)<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\">Explain why these are root causes rather than simply contributing factors. Root causes represent the deepest systemic issues that, if addressed, would prevent or significantly reduce the likelihood of recurrence.<\/p>\n<hr class=\"border-border-300 my-2\" \/>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Part 2: Evidence-Based Strategies (2-3 pages)<\/h3>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">A. Literature Review and Best Practices<\/h4>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Identify and analyze evidence-based strategies from current nursing and healthcare literature that address the root causes you identified<\/li>\n<li class=\"whitespace-normal break-words\">Cite at least 4-5 peer-reviewed sources published within the last 5 years (2020-2025)<\/li>\n<li class=\"whitespace-normal break-words\">Discuss what the evidence reveals about effective interventions for similar safety concerns<\/li>\n<li class=\"whitespace-normal break-words\">Include relevant data, statistics, or outcomes that support the effectiveness of proposed strategies<\/li>\n<\/ul>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">B. Application to Your Scenario<\/h4>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Explain how the evidence-based strategies specifically apply to your identified safety concern<\/li>\n<li class=\"whitespace-normal break-words\">Discuss the feasibility and appropriateness of each strategy for your healthcare setting<\/li>\n<li class=\"whitespace-normal break-words\">Address potential barriers to implementation and how they might be overcome<\/li>\n<li class=\"whitespace-normal break-words\">Consider interdisciplinary collaboration and stakeholder engagement needs<\/li>\n<\/ul>\n<hr class=\"border-border-300 my-2\" \/>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Part 3: Safety Improvement Plan (3-4 pages)<\/h3>\n<p class=\"whitespace-normal break-words\">Develop a comprehensive, actionable safety improvement plan that includes:<\/p>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">A. Intervention Strategies<\/h4>\n<p class=\"whitespace-normal break-words\">For each root cause identified, propose specific interventions using the E-C-A framework:<\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>E (Eliminate)<\/strong>: Interventions that eliminate the hazard entirely (e.g., remove high-risk equipment, discontinue high-risk process)<\/li>\n<li class=\"whitespace-normal break-words\"><strong>C (Control)<\/strong>: Interventions that add controls or safeguards (e.g., checklists, technology alerts, double-checks, education, process redesign)<\/li>\n<li class=\"whitespace-normal break-words\"><strong>A (Accept)<\/strong>: Interventions that acknowledge but accept the risk (generally discouraged; use only when E or C is not feasible)<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\"><strong>Note:<\/strong> Prioritize &#8220;Eliminate&#8221; and &#8220;Control&#8221; strategies. Minimize or avoid &#8220;Accept&#8221; interventions as they do not truly address safety concerns.<\/p>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">B. Implementation Plan<\/h4>\n<p class=\"whitespace-normal break-words\">For each proposed intervention:<\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Describe specific action steps for implementation<\/li>\n<li class=\"whitespace-normal break-words\">Identify responsible parties and stakeholders<\/li>\n<li class=\"whitespace-normal break-words\">Provide a realistic timeline (short-term: 0-3 months, medium-term: 3-6 months, long-term: 6-12+ months)<\/li>\n<li class=\"whitespace-normal break-words\">Outline required resources (personnel, technology, financial, educational)<\/li>\n<\/ul>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">C. Goals and Expected Outcomes<\/h4>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Define measurable goals for the safety improvement plan using SMART criteria (Specific, Measurable, Achievable, Relevant, Time-bound)<\/li>\n<li class=\"whitespace-normal break-words\">Describe expected outcomes in terms of process measures, outcome measures, and balancing measures<\/li>\n<li class=\"whitespace-normal break-words\">Explain how success will be evaluated and monitored<\/li>\n<li class=\"whitespace-normal break-words\">Discuss plans for sustainability and continuous improvement<\/li>\n<\/ul>\n<h4 class=\"text-base font-bold text-text-100 mt-1\">D. Resource Considerations<\/h4>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Identify existing organizational resources that can be leveraged (e.g., quality improvement teams, safety committees, electronic health record capabilities, staff expertise)<\/li>\n<li class=\"whitespace-normal break-words\">Describe any new or additional resources needed for successful implementation<\/li>\n<li class=\"whitespace-normal break-words\">Consider budget implications and potential cost-benefit analyses<\/li>\n<li class=\"whitespace-normal break-words\">Address potential resource constraints and alternative approaches<\/li>\n<\/ul>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Assessment Requirements<\/h2>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Format and Length<\/h3>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>Total Length:<\/strong> 8-11 pages (excluding title page and references)<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Font:<\/strong> Times New Roman, 12-point<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Spacing:<\/strong> Double-spaced<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Margins:<\/strong> 1-inch on all sides<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Format:<\/strong> APA 7th edition for all formatting, citations, and references<\/li>\n<\/ul>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Required Components<\/h3>\n<ol class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-decimal space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>Title Page<\/strong> &#8211; Include your name, course number and title, instructor name, and date<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Introduction<\/strong> (1 page) &#8211; Introduce the safety concern, its significance to patient safety and quality care, and the purpose of your analysis<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Root-Cause Analysis<\/strong> (3-4 pages) &#8211; Complete systematic analysis as outlined in Part 1<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Evidence-Based Strategies<\/strong> (2-3 pages) &#8211; Literature review and application as outlined in Part 2<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Safety Improvement Plan<\/strong> (3-4 pages) &#8211; Comprehensive plan as outlined in Part 3<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Conclusion<\/strong> (1 page) &#8211; Summarize key findings, emphasize the importance of systems thinking in patient safety, and reflect on lessons learned<\/li>\n<li class=\"whitespace-normal break-words\"><strong>References<\/strong> &#8211; Minimum of 5-7 current, peer-reviewed scholarly sources in APA format<\/li>\n<\/ol>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Evaluation Criteria<\/h3>\n<p class=\"whitespace-normal break-words\">Your assessment will be evaluated based on:<\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\"><strong>Analysis and Critical Thinking (30%)<\/strong>: Depth and thoroughness of root-cause analysis; ability to identify systemic issues beyond surface-level causes; use of structured analytical tools<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Evidence-Based Practice (25%)<\/strong>: Quality and relevance of research sources; integration of current evidence; application of best practices to the specific scenario<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Safety Improvement Plan (30%)<\/strong>: Comprehensiveness and feasibility of proposed interventions; alignment with root causes; clarity of implementation steps; consideration of resources and sustainability<\/li>\n<li class=\"whitespace-normal break-words\"><strong>Professional Communication (15%)<\/strong>: Organization and flow; clarity of writing; proper use of APA format; grammar and mechanics; professional tone<\/li>\n<\/ul>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Resources and Support<\/h2>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Recommended Tools and Frameworks<\/h3>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Joint Commission Framework for Root Cause Analysis<\/li>\n<li class=\"whitespace-normal break-words\">CMS Guidance for Performing Root Cause Analysis with Performance Improvement Projects<\/li>\n<li class=\"whitespace-normal break-words\">Institute for Healthcare Improvement (IHI) tools and resources<\/li>\n<li class=\"whitespace-normal break-words\">Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network resources<\/li>\n<\/ul>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Library Resources<\/h3>\n<p class=\"whitespace-normal break-words\">Access the Capella University Library for scholarly databases including:<\/p>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">CINAHL (Cumulative Index to Nursing and Allied Health Literature)<\/li>\n<li class=\"whitespace-normal break-words\">PubMed\/MEDLINE<\/li>\n<li class=\"whitespace-normal break-words\">Cochrane Library<\/li>\n<li class=\"whitespace-normal break-words\">Joanna Briggs Institute EBP Database<\/li>\n<\/ul>\n<h3 class=\"text-lg font-bold text-text-100 mt-1 -mb-1.5\">Writing Resources<\/h3>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Capella University Writing Center for APA formatting guidance<\/li>\n<li class=\"whitespace-normal break-words\">Grammarly or similar tools for grammar and mechanics review<\/li>\n<li class=\"whitespace-normal break-words\">SafeAssign for originality verification<\/li>\n<\/ul>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Submission Guidelines<\/h2>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">Submit your completed assessment as a Word document (.docx) or PDF<\/li>\n<li class=\"whitespace-normal break-words\">Use the assignment submission link in the courseroom<\/li>\n<li class=\"whitespace-normal break-words\">Ensure all required components are included<\/li>\n<li class=\"whitespace-normal break-words\">Verify that your document is properly formatted in APA 7th edition style<\/li>\n<li class=\"whitespace-normal break-words\">Review the scoring guide before submission to ensure all criteria are addressed<\/li>\n<\/ul>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Academic Integrity<\/h2>\n<p class=\"whitespace-normal break-words\">This assessment must reflect your own original work. Proper citation of all sources is required. Plagiarism, including self-plagiarism from previous courses, violates Capella University&#8217;s academic integrity policy and will result in serious consequences. When in doubt, cite your sources.<\/p>\n<hr class=\"border-border-300 my-2\" \/>\n<h2 class=\"text-xl font-bold text-text-100 mt-1 -mb-0.5\">Additional Notes<\/h2>\n<ul class=\"[&amp;:not(:last-child)_ul]:pb-1 [&amp;:not(:last-child)_ol]:pb-1 list-disc space-y-1.5 pl-7\">\n<li class=\"whitespace-normal break-words\">This assessment aligns with BSN program outcomes related to quality improvement, evidence-based practice, patient safety, and professional communication<\/li>\n<li class=\"whitespace-normal break-words\">The skills you develop through this assessment are essential for nursing leadership roles and quality improvement initiatives in clinical practice<\/li>\n<li class=\"whitespace-normal break-words\">Consider how this experience prepares you for real-world root-cause analyses you may conduct as a professional nurse<\/li>\n<\/ul>\n<p class=\"whitespace-normal break-words\"><strong>Questions?<\/strong> Contact your instructor through the courseroom messaging system or attend virtual office hours for clarification and guidance.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>References Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., &amp; Fairbanks, R. J. (2020). Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? BMJ Quality &amp; Safety, 29(11), 1991-1998. https:\/\/doi.org\/10.1136\/bmjqs-2019-010186 Peerally, M. F., Carr, S., Waring, J., &amp; Dixon-Woods, M. [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1439,4227,4511,4538,3859,3685],"tags":[4552,4548,4549,4550,4551],"class_list":["post-10996","post","type-post","status-publish","format-standard","hentry","category-evidence-based-practice-nursing","category-evidence-based-care","category-evidence-based-nursing-care-plans","category-evidence-based-practice-quality-improvement","category-msn-assignment-evidence-based-nursing-project-ideas","category-sample-essay-on-evidence-based-practice-in-nursing","tag-evidence-based-nursing-safety-interventions","tag-healthcare-quality-improvement-initiatives","tag-patient-safety-improvement-strategies","tag-root-cause-analysis-in-healthcare","tag-sentinel-event-prevention"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/10996","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/comments?post=10996"}],"version-history":[{"count":2,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/10996\/revisions"}],"predecessor-version":[{"id":11089,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/10996\/revisions\/11089"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/media?parent=10996"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/categories?post=10996"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/tags?post=10996"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}