Solution: 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

Week 3 Rubric – Sentinel Event Analysis Using Root Cause Analysis
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
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
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
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
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

Week 3 Rubric – Sentinel Event Analysis Using Root Cause
Analysis

Criteria

Ratings

Pts

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

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

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

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

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

Related posts:

Need help with your own assignment?

Related Articles

Week 5 Writing Assignment You are the CEO of a young, growing company. You have long expressed concern to your executive team that the company is unprepared to handle harassment claims

Assessment Task (80% of total marks) You are required to research and prepare an essay of 2,500 words in response to the following: Discuss the challenges facing retailers with regards to ensuring product availability in the shift to an omnichannel

MHA has stated that granting the license for the project to proceed is subject to the submission of a security plan: Physical Security Assignment, Singapore

Prompt For this assessment, you will create a research proposal centered on a te