you will apply the Root Cause Analysis (RCA) framework to evaluate a sentinel event. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury
In this assignment, you will apply the Root Cause Analysis (RCA) framework to evaluate a sentinel event. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. These events often signal the need for immediate investigation and response.
As a master’s-prepared nurse, you are expected to take part in systems-level thinking, quality improvement (QI), and safety planning. This activity will help you develop those competencies by analyzing an event, identifying contributing factors, and recommending actionable improvements.
Instructions:
Step 1: Choose a Sentinel Event
Select a real or hypothetical sentinel event. Examples include:
· Medication error resulting in harm
· Wrong-site surgery
· Delay in treatment
· Patient suicide in a healthcare setting
· Hospital-acquired infection leading to death
Do not include any real patient identifiers (PHI). You may draw from your own experiences, a de-identified case from clinical practice, or a published event (e.g., from The Joint Commission or news reports).
Step 2: Analyze the Event Using the RCA Framework
Use the following structure for your written analysis (2–3 pages, not including title/reference pages):
1. Brief Summary of the Event
· What happened? When and where did it occur?
2. Identify the Root Causes
· What were the contributing factors?
· Consider human, environmental, communication, and systems-level issues.
3. Propose Corrective Actions
· What could have been done differently?
· Suggest at least two specific systems-level improvements to reduce risk.
4. Role of the Advanced Practice Nurse
· How could a master’s-prepared nurse contribute to QI in this scenario?
· Include references to AACN Essentials or QSEN competencies.
Step 3: Format and Submit
· Format your paper using APA 7th edition (title page, double spacing, references).
· Include at least two scholarly references (course materials or peer-reviewed literature).
· Submit your paper as a Word or PDF file via Canvas by the deadline.
Rubric
Week 3 Rubric – Sentinel Event Analysis Using Root Cause Analysis
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Week 3 Rubric – Sentinel Event Analysis Using Root Cause
Analysis |
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Criteria |
Ratings |
Pts |
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This criterion is linked
to a Learning OutcomeSummary of Sentinel
Event |
25 to
>23.0 ptsExcellentProvides
a thorough, concise summary including timeline, key facts, and relevance to
patient safety and nursing practice. 23 to
>18.0 ptsGoodSummarizes
the event with some clarity; may lack a few key details or depth. 18 to
>0 ptsNeeds ImprovementIncomplete, vague, or unclear summary; lacks essential
components. |
25 pts |
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This criterion is linked
to a Learning OutcomeRoot Cause
Identification |
30 to
>28.0 ptsExcellentInsightful,
systems-based analysis of multiple contributing factors; demonstrates high-level
critical thinking. 28 to
>22.0 ptsGoodIdentifies
key causes; systems thinking present but underdeveloped. 22 to
>0 ptsNeeds ImprovementLimited or unclear analysis; minimal evidence of
systems-level perspective. |
30 pts |
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This criterion is linked
to a Learning OutcomeCorrective Actions
Proposed |
25 to
>23.0 ptsExcellentProposes
2+ realistic, evidence-informed solutions directly aligned with root causes. 23 to
>18.0 ptsGoodProposes
solutions that generally align with causes; details may be limited. 18 to
>0 ptsNeeds ImprovementActions are vague, unrealistic, or not clearly tied to
causes. |
25 pts |
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This criterion is linked
to a Learning OutcomeRole of APRN &
Framework Integration |
20 to
>18.0 ptsExcellentClearly
explains the APRN’s leadership role and integrates 1+ professional framework
(AACN, ANA, QSEN) meaningfully. 18 to
>14.0 ptsGoodMentions
APRN role and references a framework, though integration is limited. 14 to
>0 ptsNeeds ImprovementAPRNs not clearly referenced; missing or vague use of
framework. |
20 pts |
|
This criterion is linked
to a Learning OutcomeScholarly References |
15 to
>14.0 ptsExcellentIncludes
2+ relevant scholarly/professional sources well-integrated into the analysis. 14 to
>10.0 ptsGoodIncludes
1 scholarly source; limited integration. 10 to
>0 ptsNeeds ImprovementNo scholarly sources or poorly applied references. |
15 pts |
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This criterion is linked
to a Learning OutcomeWriting Quality &
APA Style |
10 to
>9.0 ptsExcellentClear,
well-organized writing with proper APA formatting and few or no errors. 9 to
>6.0 ptsGoodMinor grammar or APA
formatting issues that do not hinder understanding. 6 to
>0 ptsNeeds ImprovementFrequent writing or APA errors that impact clarity. |
10 pts |
