Root-Cause Analysis and Improvement Plan


Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.

For this assignment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan. You need only select one option:

The specific safety concern identified in your previous assignment.

The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation.

One of the Unit 4 case studies (linked in Resources).

A personal practice experience in which a sentinel event occurred.


The purpose of this assignment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the Root Cause Analysis and Safety Improvement Plan template linked in Resources to help you to stay organized and concise.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

Analyze the root cause of a patient safety issue or a specific sentinel event in an organization.

Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.

Create a viable, evidence-based safety improvement plan.

Identify existing organizational resources that could be leveraged to improve your plan.

Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example assignment: You may use the assignment example, linked in the resources, to give you an idea of what a Proficient or higher rating on the scoring guide would look like.

Additional Requirements

Length of submission: Use the provided template to create a 4–6 page root-cause analysis and safety improvement plan. A title page is not required but you must include a reference list as per the template.

Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

APA formatting: Format references and citations according to current APA style.


Root Cause Analysis and Safety Improvement Plan

Patient falls are a common healthcare problem globally that contributes to poor patient outcomes, increased hospital stay, and increased admission rates. According to Keuseman and Miller (2020), an estimated 40% of all hospital accidents are attributed to patient falls. Furthermore, it is the second common cause of prolonged hospital stay after adverse drug events and contributes to increased hospital expenditure, therefore becoming a healthcare burden. Consequently, it is prudent for healthcare set-ups to develop evidence-based interventions to reduce falls and limit their adverse effects. Fortunately, root cause analysis (RCA) offers an opportunity to address healthcare issues and come find solutions.

According to Paulsen. (2021), RCA is an evidenced-based tool that uses a systematic approach of incorporating principles, procedures, and methodologies to identify the root cause of the problem as well as looking for solutions to prevent such errors from occurring in the future. While assessing the cause, RCA tries to identify the risks, the steps missed, what could have been done differently, and why the incidence occurred. Therefore, when used in healthcare, RCA helps optimize care and improve patient outcomes. Regarding patient falls, this paper will discuss the root cause analysis, evidenced-based practices, safety improvement plan, and existing organizational resources to prevent falls and improve patient safety.

Analysis of the Root Cause

Root cause analysis uses a systematic approach. The initial step of RCA is problem identification and multidisciplinary team members concerned with the problem. Patient falls are a healthcare concern with several contributions classified as either internal or external causes. Interna causes are those related to patient factors. Such include increasing age above 65 years, visual impairment, urinary incontinence, dizziness, delirium, certain medications, and previous history of falls. According to Keuseman and Miller (2020), fall risks increase in elderly patients taking medications such as benzodiazepines, psychotropics, and sedatives. These medications cause drowsiness, agitation, confusion, and anxiety that increases the risk of fall in elderly patients who are essentially unstable or have gait disturbances.

Conversely, extrinsic factors are related to the environmental risks that cause falls. They include poor lighting system, overcrowding, slippery floors, negligence by healthcare providers, absence of cradles, poor communication, nursing shortage, lack of falls response system, and lack of support from relatives. Furthermore, LeLaurin and Shorr (2019) argue that despite bedside bells being useful in preventing falls, they may contribute to falls. They state that inappropriate use of bells could lead to agitation, anxiety, confusion, and an increased risk of falls. Therefore, patients and relatives must be educated before using it; otherwise, serious falls may be reported. Nonetheless, the failure of healthcare providers to identify at-risk populations also increases the risk of falls among hospitalized patients. Consequently, patient falls negatively affect patient outcomes.

For instance, patient falls contribute to fractures, dislocation, a complication of other chronic conditions, and other injuries. Therefore, it leads to increased hospitalization, which leads to increased hospital expenditures. Furthermore, patient satisfaction is compromised, making them seek legal options for compensation in case of negligence. Therefore, it is prudent to implementation of interventions aimed at reducing falls.

Application of Evidence-Based Strategies to Prevent Patient Falls.

Several levels of evidenced-based practice have been deployed in various set-ups to prevent patient falls. One of the most common causes of patient falls is due to negligence. Therefore, my institution has been at the forefront of offering education to healthcare providers about their roles and how they can prevent falls. The education aims at enlightening caregivers about risks, prevention strategies, and complications of falls. The use of a risk assessment tool for all patients is the easiest and safest way of classifying patients (Stoeckle et al., 2019). For those at high risk, extra activities are performed. Such include hourly rounding, close monitoring, placing them in safe beds, offering them bracelets, and training caregivers. Furthermore, prompt medication analysis should be done to eliminate sedative medications from high-risk patients.

Moreover, other interventions applicable to reducing falls involve addressing environmental factors. Such include improving lighting, avoiding slippery floors, addressing nursing shortages, improving communication strategies, and implementing protocols for fall prevention. According to Francis-Coad et al. (2020), an increasing number of healthcare providers will reduce workload and burnout, thus improving the patient environment while eliminating risks, leading to increased patient safety. Furthermore, patients should be educated about the importance of effective communication with healthcare providers and relatives before leaving their beds.

Improvement Plan with Evidence-Based and Best Practice Strategies

Incorporation of the patient safety improvement corps (PSIC) is the safest method that has been used in various healthcare settings to reduce patient falls. PSIC is a nationwide program in the US for training healthcare providers in safety techniques (LeLaurin & Shorr, 2019). It aims at improving the knowledge and skills of healthcare providers about their safety and that of their patients. Regarding patient falls, PSIC encourages the use of risk assessment tools and post-fall assessment tools. The goal of PSIC is to ensure a reduction in falls in a specific setup and initiate mass education of all healthcare providers about the safety techniques.

The risk assessment tools have several questions that help screen all patients as they are admitted. This ensures that high-risk patients are identified while safety steps are implanted to reduce falls. On the other hand, the post-fall assessment tool helps identify both intrinsic and extrinsic factors that may have contributed to falls (Francis-Coad et al., 2020). Once identified, safety measures are put in place to address the risks to prevent future occurrence of falls. Therefore, all healthcare providers should be equipped with PSIC training to improve patient safety.

Existing organization Resources to Prevent Patient Falls

Falls prevention is a significant healthcare issue requiring various stakeholders’ input while incorporating various resources. As stated earlier, the PSIC program aims at offering training to improve safety. However, there is a need to team members to implement the PSIC training to enhance safety. Therefore, all healthcare providers, including nurses, doctors, therapists, and pharmacists, among others, should be included in the training. After acquiring skills, these members can then train others, including security personnel, patients, and relatives, about safe practices to prevent patient falls (Stoeckle et al., 2019). Finally, resources, including brochures, cards, and papers containing safety measures, can be distributed to patients, insurance companies, relatives, and other healthcare providers to improve knowledge.


Despite patient falls being a healthcare problem resulting in adverse patient outcomes, root causes analysis offers a systematic approach to reducing falls. RCA identifies the cause of a problem as well as comes up with a solution to prevent future occurrences. Known causes of patient fall include impaired vision, negligence by nurses, sedating medications, gait disturbances, slippery floor, and poor lighting. Therefore, RCA helps in deep investigation of the root cause and finding solutions. The commonly applied solutions to prevent falls are by educating healthcare providers about safety techniques and improving the working environment.



Francis-Coad, J., Hill, A.-M., Jacques, A., Chandler, A. M., Richey, P. A., Mion, L. C., & Shorr, R. I. (2020). Association between characteristics of injurious falls and fall preventive interventions in acute medical and surgical units. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences75(10), e152–e158.

Keuseman, R., & Miller, D. (2020). A hospitalist’s role in preventing patient falls. Hospital Practice (1995)48(sup1), 63–67.

LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine35(2), 273–283.

Paulsen, M. (2021). Root cause analysis. JAMA: The Journal of the American Medical Association325(3), 225–226.

Stoeckle, A., Iseler, J. I., Havey, R., & Aebersold, C. (2019). Catching quality before it falls: Preventing falls and injuries in the adult emergency department. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association45(3), 257–264.


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