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 - StudyAce – Custom Writing & Research Support for All Levels

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

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