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

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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: 

ESSAY WRITING AGENCY

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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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