Introduce a general summary of the issue or sentinel event that the root-cause analysis (RCA) will be exploring. Provide a brief context for the setting in which the event took place. Keep this short and general. Explain to the reader what will be discussed in the paper and this should mimic the scoring guide/the headings.Analysis of the Root CauseDescribe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:
What happened?Who detected the problem/event?Who did the problem/event affect?How did it affect them?
What was supposed to occur?
Were there any steps that were not taken or did not happen as intended?
What environmental factors (controllable and uncontrollable) had an influence?What equipment or resource factors had an influence?What human errors or factors may have contributed?Which communication factors may have contributed?Describe what the literature states about the factors that lead to the safety issue.
For example, interruptions during medication administration increase the risk of medication errors by specifically stated data. Explain how the strategies could be addressed in safety issues or sentinel events.
Actions, new processes or policies, and/or professional development that will be undertaken to address one or more of the root causes.
Support these recommendations with references from the literature or professional best practices.
A description of the goals or desired outcomes of these actions.A rough timeline of development and implementation for the plan.A brief note on resources that may need to be obtained for the success of the plan.Consider what existing resources may be leveraged to enhance the improvement plan?