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NURS FPX 6222 Assessment 2: Root-Cause Analysis and Safety Improvement Plan

  • March 2, 2026
  • 12 min read
  • 2,847 downloads
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Assessment Overview:

NURS FPX 6222 Assessment 2 focuses on conducting a comprehensive Root-Cause Analysis (RCA) and developing an evidence-based safety improvement plan to reduce patient harm and strengthen healthcare systems. Students are expected to analyze a sentinel event—such as a medication error—by identifying system-level failures related to communication, staffing, workflow, training, and technology rather than assigning individual blame. The assessment emphasizes the structured application of RCA tools, including the “5 Whys,” Fishbone (Ishikawa) Diagram, and Failure Mode and Effects Analysis (FMEA), as recommended by the Agency for Healthcare Research and Quality.

Learners must design a practical and measurable safety improvement plan aligned with national patient safety standards from the Centers for Disease Control and Prevention and quality improvement frameworks from the Institute for Healthcare Improvement. Key components include standardized communication tools such as SBAR, double-check systems for high-alert medications, improved staffing strategies, enhanced competency training, and strengthened health information technology safeguards. Ethical and legal considerations—including patient rights and compliance with HIPAA regulations outlined by the U.S. Department of Health and Human Services—must also be addressed.

Key Objectives

  • Identify and articulate a relevant clinical nursing issue
  • Locate and evaluate credible, peer-reviewed research sources
  • Apply APA 7th edition formatting and citation standards
  • Demonstrate critical thinking and evidence synthesis

Understanding the Requirements

  • Length: 4-6 pages (excluding title page and references)
  • Format: APA 7th edition, double-spaced, 12pt Times New Roman
  • Sources: Minimum 3-5 peer-reviewed articles from the last 5 years
  • Content: Identify a clinical issue, locate credible sources, and explain how research informs practice

Criteria

  • Research Application
  • Source Quality
  • APA Formatting

Distinguished

  • Expertly applies research to clinical issue
  • All sources highly credible and current
  • Perfect APA 7th edition

Proficient

  • Adequately applies research
  • Most sources credible
  • Minor APA errors
  • Use CINAHL, PubMed, or Cochrane Library for high-quality sources
  • Ensure all citations match references exactly
  • Demonstrate critical thinking, not just summarizing sources
  • Proofread carefully for grammar and clarity

Complete Assessment Outline

Introduction

• Introduce the clinical issue or topic
• Explain its relevance to nursing practice
• State the purpose of the assessment

Research Process

• Describe databases and search strategies used
• Explain criteria for selecting credible sources
• Discuss evaluation of source quality and relevance

Evidence Synthesis

• Summarize key findings from research sources
• Compare and contrast different perspectives
• Identify patterns and themes in the evidence

Application to Practice

• Explain how research informs clinical decisions
• Provide specific examples of practice applications
• Discuss implications for patient outcomes

Conclusion

• Summarize key points and findings
• Reinforce the importance of evidence-based practice
• Suggest areas for future research or practice improvement

How to Pass NURS FPX 6222 Assessment 2: Root-Cause Analysis and Safety Improvement Plan

  • Read the Rubric Precisely: Make sure you easily address the RCA process, root causes, and a detailed safety enhancement plan. 
  • Describe the safety event by clearly summarizing the incident (e.g., drug error) and explaining its impact on the case and the associated outcomes. 
  • Conduct a Structured RCA Identify system-position causes (communication, staffing, training, technology)—not just individual miscalculations. 
  • Use RCA Tools: Mention tools like the 5 Whys or Fishbone Diagram to show structured analysis. 
  • Identify Root Causes: Easily list the main underpinning system failures that led to the event. 
  • Develop a substantiation-grounded safety plan Propose practical results similar to SBAR, double-check systems, staffing adaptations, and technology advancements. 
  • Support With Believable Sources: Reference guidelines from the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. 
  • Include Outcome Measures Define clear criteria (e.g., reduced error rates, bettered compliance, staff/faculty scores). 
  • Address Ethical and Legal Considerations: citation HIPAA compliance and patient safety principles. 
  • Organize easily Structure your paper as preface → Event Summary → RCA Findings → Root Causes → Safety Plan → Evaluation → Conclusion.
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Sample Assessment Paper

Introduction: The Role of RCA in Patient Safety

Healthcare associations work hard to make places where people are less likely to get hurt and where they can get good care. Despite the perpetration of these measures, misapprehensions similar to incorrect drug administration, falls, and infections in homes persist. The Institute of Medicine says that medical misapprehensions are one of the main causes of illness and death, killing more than 250,000 people in the U.S. each time (Johns Hopkins Medicine, 2023). 

Root-cause analysis (RCA) gives you a way to look into misapprehensions, find problems with the system, and come up with specific ways to fix them. RCA helps healthcare armies put in place long-lasting safety results by looking at the root causes of problems rather than just the symptoms. 

Case Scenario: Medication Error Event

NURS FPX 6222 Assessment 2:Event Summary

A 68-year-old man with congestive heart failure was given twice the specified dose of digoxin by mistake, which caused severe bradycardia and transferred him to the ICU. The mistake was set up four hours after the medicine was given during routine monitoring of vital signs. Case Impact demanded to be moved to ferocious care. 

  • Had low blood pressure and heart meter problems.
  • Seven further days in the sanitarium.
  • Advanced healthcare costs and internal stress for the case and their family.

This incident shows how important it is to do a full root-cause analysis and make safety advancements at the system position. 

Step 1: Conducting a Root-Cause Analysis (RCA)

RCA looks into not only what happened but also why it happened. We set up the preceding corridor.

1. Communication Breakdown

  • The verbal handoff between the night and day shift nurses wasn’t complete. 
  • The EHR didn’t record the change in the cure of digoxin. 

2. Medication Administration Errors

  • The nanny skipped surveying the barcode because the system was down. 
  • There is no protocol for double-checking high-alert specifics. 

3. Staffing and Workload

  • The unit didn’t have enough staff, which made it hard to give out specifics snappily. 
  • The nurse was in charge of ten cases, which is further than what is safe. 

4. Training and Competency Gaps

  • Training on how to handle high-alert specifics isn’t always the same. 
  • There is no yearly test of how well you can give digoxin. 

5. Technology and System Failures

  • The barcode scanning software isn’t working. 
  • The EHR alert system didn’t flag the high cure. 

Root Causes Identified

  • Not enough communication during the handoff. 
  • No double-check system for high-trouble drugs. 
  • Unsafe rates of staff to cases. 
  • Bad technology structure and planning for extremities. 
  • There are gaps in the ongoing education and faculty checks for nurses. 

Safety Improvement Plan

The RCA findings suggest the following validation-predicated plan for making safety better. 

1. Standardize Communication with SBAR

  • Use the SBAR (Situation, Background, Assessment, Recommendation) tool for all handoffs. 
  • Bear that EHRs be streamlined within 15 beats of changes to medicine orders. 

2. Enhance Medication Safety Protocols

  • Double-Check Policy Before giving out grandly alert specifics, two licensed nurses must check them. 
  • Compliance with Barcode Scanning Make sure backup systems are available when the main ones go down. 
  • EHR safety cautions Change the algorithms so they can find capsule crimes. 

3. Optimize Staffing Levels

  • Follow Corpus guidelines for staffing rates (14 for medical-surgical units). 
  • Use peer pools and flexible staffing models to deal with harpoons. 

4. Improve Training and Competency

  • Every time, everyone must go through training on high-trouble specifics. 
  • Use simulation-tested faculty testing to make sure specifics are safe. 

5. Strengthen Technology Infrastructure

  • Add redundancy features to your barcode systems. 
  • Make sure that apothecary systems and EHRs work together so that tablets can be checked in real time. 

Ethical and Legal Considerations

  • Ethical and legal morals must guide sweats to keep cases safe. 
  • Cases have the right to watch that’s safe and free of misapprehensions. 
  • Beneficence and nonmaleficence mean that healthcare workers must do what’s suitable for the case and avoid causing detriment. 
  • Responsibility Associations must be open about their misapprehensions and give the right follow-up care. 
  • HIPAA Compliance: All examinations into incidents must cover the sequestration of cases (HHS, 2024). 

Outcome Measures and Evaluation

  • We’ll keep track of the following criteria to see how well the safety enhancement plan works. 
  • Rates of drug crimes Within a time, you should try to cut it in half. 
  • Handoff Communication Compliance: Aim for a 95% SBAR attestation rate. 
  • Barcode Scanning Compliance The thing is for everyone to follow the rules. 
  • Staff faculty scores To pass the periodic test, you need to get at least 90. 
  • A check of patient safety culture Staff’s sense of safety has gone up by 30. 

Continuous Quality Improvement (CQI)

  1. Making goods safer is an ongoing process. To make sure that monitoring and enhancement never stop, we will use the Plan-Do-Study-Act (PDSA) model. 
  2. Plan: Find ways to make farther goods and make plans for how to do them. 
  3. Do make small changes. 
  4. Study Look at the data and judge the results. 
  5. Act to make successful interventions bigger and change bones that don’t work. 

How-To: Steps to Conduct an RCA and Safety Plan

  1. Find the bad event, get information, and write down how it affects you. 
  2. Put together a team for RCA that includes nurses, croakers, apothecaries, IT experts, and trouble directors. 
  3. Get the information, look over EHRs, talk to staff, and look over protocols. 
  4. Find the root causes with tools like the “5 Whys” or the Fishbone Diagram. 
  5. Make safety results Don’t condemn people; just change the system. 
  6. Put into action and keep an eye on effects Keep an eye on progress and make changes to interventions as demanded. 

Conclusion

Crimes involving medicines are avoidable, but they are still a major cause of detriment to cases. Healthcare associations can find and fix the root causes of bad events and put in place long- term safety measures by doing a root-causeterm analysis. Organizations can greatly lower misapprehensions and promote a culture of safety by using standardized communication, better staffing, better training, and better use of technology.

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References

  1. The Agency for Healthcare Research and Quality (AHRQ). (2024). Template for a Root Cause Analysis and Action Plan. https://www.ahrq.gov
  2. The CDC, or Centers for Disease Control and Prevention. (2024). Errors in medication and patient safety. https://www.cdc.gov
  3. Johns Hopkins Medicine. (2023). Medical mistakes are one of the main things that kill people. https://www.hopkinsmedicine.org
  4. U.S. Department of Health and Human Services. The Privacy Rule of HIPAA. https://www.hhs.gov/hipaa
  5. Institute for Improving Healthcare (IHI). (2023). Using PDSA cycles to make things better. https://www.ihi.org
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Rubric Breakdown

Criteria Exemplary (4) Proficient (3) Developing (2) Needs Improvement (1)
RCA Analysis Thoroughly identifies all root causes; clear use of RCA tools; deep understanding of system failures. Identifies most root causes; RCA tools mostly applied correctly. Identifies some root causes; limited or inconsistent use of RCA tools. Minimal or inaccurate identification of root causes; RCA tools not used.
Safety Improvement Plan Comprehensive, evidence-based interventions addressing all identified causes; clear, actionable steps. Plan addresses most causes; mostly evidence-based; some steps need clarification. Plan partially addresses causes; limited evidence or unclear steps. Plan missing or poorly developed; not evidence-based.
Implementation Strategies Clear, realistic strategies with assigned responsibilities, timeline, and measurable outcomes. Strategies mostly clear; minor gaps in responsibilities or outcomes. Strategies present but vague or incomplete. Strategies unclear, unrealistic, or missing.
Outcome Measurement & Evaluation Measurable outcomes clearly defined; includes quantitative and qualitative indicators; evaluation plan detailed. Outcomes mostly measurable; minor gaps in indicators or evaluation. Outcomes vague or partially measurable; evaluation plan limited. Outcomes missing or not measurable; evaluation plan absent.
Ethical and Legal Considerations Fully addresses patient rights, HIPAA compliance, and ethical principles; culturally sensitive. Some ethical/legal considerations addressed; mostly compliant. Limited ethical or legal considerations; cultural sensitivity minimal. Ethical/legal considerations missing; not culturally sensitive.
Interprofessional Collaboration Clear involvement of multiple disciplines in RCA and safety plan; promotes teamwork. Collaboration mostly addressed; minor gaps in team involvement. Limited collaboration or unclear team roles. Collaboration not addressed.
Writing & Organization Well-organized, professional, APA-compliant, clear flow of ideas. Mostly organized; minor APA or clarity issues. Some structure or clarity issues; APA partially followed. Poorly written, unorganized, lacks APA compliance.
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Step-by-Step Guide

  1. Describe the Safety Event – epitomize the incident (e.g., drug error) and its impact on the case. 
  2. Assemble RCA Team – Include nurses, croakers, druggists, IT, and threat/safety directors. 
  3. Collect Data—Review EHRs, protocols, staff interviews, and covering reports. 
  4. Identify Contributing Factors – Examine communication, staffing, training, technology, and workflow gaps. 
  5. Use RCA Tools – Apply “5 Whys,” Fishbone Diagram, or FMEA to trace root causes. 
  6. List Root Causes – Highlight underpinning system failures, not individual blame. 
  7. Develop Safety Improvement Plan – Include SBAR handoffs, double-checks, staffing adaptations, training, and tech upgrades. 
  8. Define Outgrowth Measures – Set criteria like error rate reduction, SBAR compliance, staff faculty, and patient safety culture. 
  9. Address Ethical Legal Considerations – Ensure HIPAA compliance, patient safety, beneficence, and responsibility. 
  10. Apply CQI—Use PDSA cycles for nonstop monitoring, evaluation, and plan refinement.
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Frequently Asked Questions (FAQ's)

  1. Why do a root-cause analysis? 

The purpose of a root-cause analysis is to identify the underlying causes of system failures that result in crimes and devise strategies to prevent their recurrence. 

  1. What part do nurses play in RCA? 

Nurses are the first people to see problems with workflow, communication, and patient safety. 

  1. What tools do people generally use in RCA? 

The “5 Whys,” the Fishbone Diagram (Ishikawa), and Failure Mode and Goods Analysis (FMEA) are all tools. 

  1. What makes SBAR so important for safety? 

It makes sure that communication is structured and homogenized, which lowers the chances of making misapprehensions. 

  1. What are the signs that a safety improvement plan is working? 

By using criteria like lower error rates, better compliance, advanced staff chops, and better case issues.

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NURS FPX 6222 Assessment 2

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