Root Cause Analysis (RCA)
Overview
This assignment provides an opportunity for students to apply principles of a root cause analysis in the evaluation of a sentinel event that is observed in a preselected video. The risk management process of a root cause analysis is applied using a fishbone diagram and the five “why” questions.
How to Use
Students are introduced to the root cause analysis process and sentinel events through several pre-assignment readings and videos:
- Connelly, L. (2018). Voice of the process. Medsurg Nursing, 27(4), 262-263.
- Haney, K. (2020). Root cause analysis: A pediatric case study. The Journal of Legal Nurse Consulting, 31(4), 26-29.
- JCAHO Sentinel Event Policy (2024): https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/sentinel-event-policy-and-procedures
- Karkhanis, A.J., & Thompson, J. M. (2021). Improving the effectiveness of root cause analysis in hospitals. Hospital Topics 99(1), 1-14. https://doi.org/10.1080/00185868.2020.1824137
- Whiteman, K., Yaglowski, J., & Stephens, K. (2021). Critical thinking tools for quality improvement projects. Critical Care Nurse, 41(2), e1-e9.
- Videos:
- Institute for Healthcare Improvement (2018, November 1). Ask “why” five times [Video]. YouTube. https://www.youtube.com/watch?v=3QOy1DyTFJY
- Invensis Learning (2021, April 1). Root cause analysis techniques [Video]. YouTube. https://www.youtube.com/watch?v=oMZg-Q8EBek
- Institute for Healthcare Improvement (2018, November 1). Ask “why” five times [Video]. YouTube. https://www.youtube.com/watch?v=3QOy1DyTFJY
- Following completion of the pre-assignment readings and videos, the student selects one of the following videos of a real-life sentinel event to view:
- Doncaster and Bassetlaw Teaching Hospitals (2014, September 8). The human factor: Learning from Gina’s story [Video]. YouTube. https://www.youtube.com/watch?v=IJfoLvLLoFo
-or-
- Laerdal Medical (2011, July 6). Just a routine operation: Human factors in patient safety [Video]. YouTube. https://www.youtube.com/watch?v=JzlvgtPIof4
- Doncaster and Bassetlaw Teaching Hospitals (2014, September 8). The human factor: Learning from Gina’s story [Video]. YouTube. https://www.youtube.com/watch?v=IJfoLvLLoFo
Integrative Learning Strategies
The goals of this assignment include using clinical judgment, compassionate care and ethical consideration skills to analyze a simulated sentinel event. As the student completes a fishbone diagram, they actively engage in selected steps of the root cause analysis process to identify the factors and variables that contributed to the sentinel event. Students will apply the “ask five why” questions technique that could be asked during the process of a root cause analysis. At the end of the assignment, students provide specific recommendations for improving quality and safety in the environment where the sentinel event occurred, and reflect upon the content in this module.
Assessment Strategies
RCA and Fishbone Assignment Guidelines and Rubric
Learning Objectives
Upon successful completion of this assignment, the student will:
- Define a sentinel event.
- Analyze a sentinel event to determine contributing factors and variables.
- Document root cause analysis findings in a Fishbone diagram.
- Apply the “Ask Five Why” questions technique to explore factors and variables that contributed to the sentinel event.
- Generate recommendations for improving quality and safety in the workplace environment.
Possible Courses
- Undergraduate (Prelicensure and/or RNBS) quality and safety course
- Undergraduate (Prelicensure and/or RN BS) quality and safety content that is integrated across the curriculum in different courses. (Select the most appropriate course for this assignment, or modify it by selecting different sentinel event videos that align with clinical content featured in a specific course)
Additional Resources/Publications
Sub-competencies for entry-level professional nursing education:
1.1b Apply knowledge of nursing science that develops a foundation for nursing practice.
1.1d Articulate nursing’s distinct perspective to practice.
1.2a Apply or employ knowledge from nursing science as well as the natural, physical and social sciences to build an understanding of the human experience and nursing practice.
1.2b Demonstrate intellectual curiosity.
1.2c Demonstrate social responsibility as a global citizen who fosters attainment of health equity for all.
1.2d Examine influence of personal values in decision-making for nursing practice.
1.2e Demonstrate ethical decision-making.
1.3a Demonstrate clinical reasoning.
1.3b Integrate nursing knowledge (theories, multiple ways of knowing, evidence) and knowledge from other disciplines and inquiry to inform clinical judgment.
1.3c Incorporate knowledge from nursing and other disciplines to support clinical judgment.
5.1f Identify strategies to improve outcomes of patient care in practice.
5.2a Describe the factors that create a culture of safety.
5.2e Describe the processes used in understanding causes of error.
9.1b Reflect on one’s actions and their consequences
9.3h Engage in peer evaluation
Posted: December 12, 2025
Submitted by:
Lynn Nichols, PhD, RN, PED-BC, SANE, ANEF, Associate Professor, RN-BS Program Director, Boise State University
If you would like to cite this resource in your own work, please use the following citation:
Nichols, L. (2025). Root Cause Analysis (RCA). Excerpted from the Essentials Teaching Resource Database. American Association of Colleges of Nursing, Washington, DC. Available at https://www.aacnnursing.org/AACN-Essentials/Implementation-Tool-Kit.