Define the problem – Describe the incident

Medication Error




  1. Define the problem – Describe the incident
  2. Measure – What was the defect? How many?  How often?
  3. Analyze – How did this happen? What is the normal process?
  4. Improve – How/what are we going to do to prevent this from reoccuring?
  5. Control – If you put into place something where data is measured – who is responsible for following up?





Root Cause Analysis Paper and Rubric (Total Weight: 20%) 

This paper is based on the root cause analysis (RCA) that you will conduct based on an incident report.  Your paper should describe the incident, the process taken to complete the RCA and the gap identified between current patient outcomes and desired patient outcomes.   In writing this paper, you will use evidence-based practice to develop your recommendations and suggest two teaching topics that would enhance a culture of safety and mitigate reoccurrence of the incident.

Papers should be written in APA 6th edition format in Times New Roman font size 12.  The details for the flow of your paper are listed below:

  • Cover page
    • Title
    • Course (semester)
    • Learner name
    • Professor name
    • Date
  • Introduction
    • Brief description of incident, RCA, gap identified, mention of literature review (evidence to support gap), teaching opportunity
    • Purpose of the paper
  • Body of paper
    • Detailed description of incident
    • Detailed description of RCA and process
    • Identification of gap in current and desired patient outcomes
    • Literature review (you may use more than the two required articles, you may also use your text as a reference if appropriate)
      • Article #1
        • Describe how article supports or negates findings based on RCA
      • Article #2
        • Describe how article supports or negates findings based on RCA
      • Critique of literature
        • Compare and contrast articles
      • Synthesize findings
    • Staff development teaching recommendations
      • Two suggested educational offerings that would enhance
        • Culture of safety
        • Mitigate reoccurrence
      • Conclusion
        • Summarize the document
        • Discuss how findings are an addition to nursing practice/nursing education (support with literature)
      • Reference page
      • Appendix
        • Include your RCA as an appendix

Recommendations for refining your paper:

  • Be sure to use in-text citations to support your prose
  • Conduct a spelling and grammar check prior to submitting your paper
  • Run your document through SafeAssign to ensure that you have less than 20% similarities to others’ work
  • You may submit drafts of the completed draft of your document for review/feedback to the course professor prior to the due date


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