NursingWritten assignmentPatient safety

Root-cause analysis and safety improvement plan guide

A template-driven root-cause analysis whose five bullets are the scoring guide — and where the two highest-cost mistakes are a plan built on staff education and a resources section that asks for things the organisation does not yet have.

Aug 8, 2026Updated Aug 10, 2026

Editorial process

Last reviewed · August 8, 2026

Written by

Aaron Bishop

MA, Education

assignment interpretation and research-methods coaching across disciplines

Reviewed by

Dr. Nathan Cole

PhD, Rhetoric & Composition

Argumentation and thesis development

On this page

Interpret the task
Assignment instructions
Deliverables
Proposed outline
Research plan
Reference shortlist
Final review

What does this root-cause analysis assessment actually score?

Read the five bullets under *Instructions* as the section plan, because the brief says outright that they correspond to the grading criteria in the scoring guide. Analyse the root cause; apply evidence-based and best-practice strategies; create a feasible, evidence-based plan; identify organisational resources that could be leveraged; write it professionally in APA. That is five scored things, and the supplied Root-Cause Analysis and Improvement Plan template exists to keep them separable. Writing this as a flowing narrative about a sentinel event is the commonest structural failure here: the content may all be present, but a marker working down a scoring guide has to find each criterion, and prose that blends cause into plan into resources makes four of the five hard to award. Use the template's headings and let the structure do that work for you.

The root-cause requirement has a floor that catches most drafts. A root cause is a process or system failure, and an analysis that terminates at a person — the nurse was distracted, the physician was rushed, staff did not follow policy — has stopped one level too early. The brief signals this by naming *process and system-check failures* explicitly. Keep asking what allowed that human error to reach the patient: what check was absent, what handoff had no structure, what alert was suppressed, what workaround had become normal. It is also worth knowing that the term itself is contested — AHRQ notes that serious events almost never have a single root cause, and that multiple intersecting failures are the norm. Naming several linked causes is more defensible than manufacturing one. Say which check was missing, not only that one was, because the plan later has to put something in its place.

The plan criterion contains the trap that costs the most marks, and it is nearly invisible. The default safety improvement plan proposes staff education: an in-service, a competency day, a refresher module. That is the weakest tier of intervention, and it is not a matter of opinion — AHRQ's own analysis of why root-cause analyses fail to produce sustainable change lists reliance on weak solutions such as educational programmes first among the reasons. So a plan resting on education alone is arguing against the evidence base the same assignment asks you to apply. Pair it with something structural: a forcing function, a change to the order set, barcode verification, a standardised handoff, a physical or technological constraint that makes the error harder to commit in the first place. Education can stay in the plan; it just cannot be the whole of it.

*Identify existing organizational resources that could be leveraged to improve your plan* is the criterion most often answered wrongly, and the error is one word. The resources must be **existing** ones at your chosen setting. Proposing to hire more nurses, buy a new system or fund a new role identifies resources you do not have, which is the opposite of what is asked. Look instead for what is already there and under-used: a standing quality or safety committee, a nurse educator, an existing incident-reporting system, EHR alerting capability nobody has configured, unit huddles, a pharmacist already on rounds, policies written but not audited. This criterion is also what makes the plan *feasible* — the two are linked, and a plan buildable from the resources you just named answers both at once. Walk the unit in your head and list what is already there before you write a single recommendation.

Two mechanical requirements are worth checking before you start writing rather than after. The submission is four to six pages built on the supplied template, with no title page required but a reference list that is — an inversion of the usual APA expectation that trips people who format from habit. And the sources must be scholarly or professional, at least three of them, and **no more than five years old**. That recency limit quietly disqualifies the classics this topic attracts: the 1999 Institute of Medicine report, the original Swiss cheese paper, foundational sentinel-event literature. Cite them if they help the argument, but they do not count toward your three, so build the required minimum from current guidance and recent peer-reviewed work first. Check the template for a reference page before formatting anything, since it governs over habit here.

Scoring criterion	What a distinguished answer contains	The common miss
Analyze the root cause	A process or system failure, often several linked	Stopping at human error or non-compliance
Apply evidence-based strategies	Named practices with current citations	Generic best practice with no source
Create a feasible plan	At least one strong, structural intervention	Staff education alone — the weakest tier
Identify organizational resources	Assets that already exist at the setting	Requesting new hires, budget or systems
Communicate professionally in APA	Template headings, reference list, no title page	Free-form narrative and a title page
Source requirements	3+ scholarly/professional, under 5 years old	Counting the 1999 IOM report toward the three

Likely learning objectives

Inferred from the brief — check these against your own rubric.

01
Trace a patient safety event past individual error to the process or system failure that permitted it.
02
Distinguish strong structural interventions from weak educational ones when designing improvement.
03
Ground feasibility in an inventory of resources an organisation already holds.
04
Apply a recency constraint to source selection rather than defaulting to foundational literature.

Assignment instructionsQuoted verbatim

Read the full question

Review every instruction before using the planning guidance that follows.

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue. As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes. As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: Competency 1: Analyze the elements of a successful quality improvement initiative. Root-Cause Analysis And Safety Improvement Plan DQ Apply evidence-based and best-practice strategies to address a safety issue or sentinel event. Create a feasible, evidence-based safety improvement plan. Competency 2: Analyze factors that lead to patient safety risks. Analyze the root cause of a patient safety issue or a specific sentinel event within an organization. Competency 3: Identify organizational interventions to promote patient safety. Identify existing organizational resources that could be leveraged to improve a plan. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Professional Context 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. Scenario For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan: The specific safety concern identified in your previous assessment. The Vila Health: Root-Cause Analysis and Safety Improvement Planning simulation. One of the case studies from the previous assessment. A personal practice experience in which a sentinel event occurred. Instructions The purpose of this assessment 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 Improvement Plan Template [DOCX] to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process. 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 feasible, evidence-based safety improvement plan. Identify 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 Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like: Assessment 2 Example [PDF]. Additional Requirements Length of submission: Use the provided Root-Cause Analysis and Improvement Plan 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. Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click the linked resources for helpful writing information. Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course.

What the template has to contain

01
A root-cause analysis of one safety issue or sentinel event, built on the supplied template.
02
Evidence-based and best-practice strategies applied to that specific issue.
03
A feasible safety improvement plan with defined actions.
04
An identification of existing organisational resources that could be leveraged.
05
Four to six pages, no title page, with a reference list per the template.
06
At least three scholarly or professional sources, none more than five years old, in current APA style.

From the sentinel event to a feasible improvement plan

The safety issue or sentinel event

Define the event and the setting precisely enough that a cause can be scoped to it.

Root-cause analysis

Work back from the event through contributing factors to the process or system failures involved.

Evidence-based and best-practice strategies

Set out what current literature and professional guidance recommend for this class of failure.

The safety improvement plan

Convert the strategies into defined actions, owners and measures for this setting.

Existing organisational resources

Inventory the committees, roles, systems and routines already available to carry the plan.

Finding evidence that meets the five-year rule

Recommended databases

AHRQ Patient Safety Network (PSNet)
CINAHL
PubMed
The Joint Commission resource library

Search sequence

1.
Filter every search to the last five years before you start reading, because the brief's recency rule decides which of what you find can count toward the minimum.
2.
Search the specific event type — falls, medication error, wrong-site surgery, healthcare-associated infection — rather than patient safety in general, so the strategies you cite match the failure you analysed.
3.
Look specifically for evidence on intervention strength, so the plan can justify choosing a structural change over an educational one rather than defaulting.
4.
Inventory the chosen organisation's existing structures last, and write the plan against that list, since feasibility is graded against what is already available.

Patient safety sources for the analysis and the plan

These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.

Nothing here is cleared for citation until you have read it.

01
Root Cause Analysis | PSNet
Patient Safety Network, Agency for Healthcare Research and Quality · 2024
The single most useful source for this assessment, and the one that supplies its sharpest argument: RCAs frequently fail to produce sustainable change, and reliance on weak solutions such as educational programmes is among the documented reasons. Cite it to justify choosing a structural intervention. It also explains why 'root cause' is a misleading singular.
02
Medical Error Prevention and Root Cause Analysis - StatPearls
StatPearls Publishing, via NCBI Bookshelf · 2024
The procedural detail behind an RCA — the accreditor's reporting expectations and corrective-action timeframe, plus the distribution of sentinel event types, with falls the largest category. Useful for situating your chosen event and for the claim that most errors are system-level rather than individual, which is the standard your analysis has to meet.
03
Patient Safety 101
Patient Safety Network, Agency for Healthcare Research and Quality · 2024
The systems framing your analysis has to adopt, including Reason's Swiss cheese model and the point that catastrophic failures are almost never isolated individual errors. It also names interventions with demonstrated impact — computerised order entry, barcode medication administration — which is where to look for a strong action to anchor the plan.
04
Culture of Safety
Patient Safety Network, Agency for Healthcare Research and Quality · 2024
The just-culture distinction between human error, at-risk behaviour and reckless behaviour, which lets the analysis address individual conduct without collapsing into blame. Also useful for the resources section: an existing incident-reporting system and a blame-free reporting norm are organisational assets you can leverage rather than build.

Before the analysis is submitted

Common mistakes

Ending the root-cause analysis at human error rather than at the system failure behind it.
Writing a narrative about the event instead of using the template's headings, so criteria are hard to score.
Proposing staff education as the whole improvement plan, which the evidence identifies as a weak intervention.
Listing resources the organisation would need to acquire instead of ones it already has.
Treating feasibility as a separate claim rather than as something the resources section has to support.
Citing the 1999 Institute of Medicine report or other classics toward the three-source minimum.
Adding a title page the template does not require while omitting the reference list it does.
Choosing a safety issue so broad that no single root cause or plan can be scoped to it.

Submission checklist

The analysis names a process or system failure, not only a person's action.
Each of the five scoring criteria is findable under its own heading.
The plan includes at least one intervention stronger than education or reminders.
Every resource named already exists at the chosen setting.
Feasibility is argued from those named resources.
At least three sources are scholarly or professional and under five years old.
The template's structure is intact, with a reference list and no title page.
APA formatting is applied to both citations and references.

Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.