This assignment is the second part of a series of assignments related to your fi

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This assignment is the second part of a series of assignments related to your final course immersion project. The first part of the assignment series was choosing an appropriate topic. The Root Cause Analysis (RCA) assignment begins in Module 2 but is due at the end of Module 3.
The goal of this paper is to apply the principles of the Root Cause Analysis to a problem or opportunity for improvement in your workplace. This assignment requires systems thinking and problem solving by identifying contributing factors or root causes to an adverse event without assigning blame to individuals.
Guidelines
Briefly present the situation, error/adverse event or case study. This is the “what happened?” portion of the RCA. Do not include any organizational, patient or staff identifiers. Be sure to include the impact on the patient, family and staff involved.
Next, present “why did it happen?” portion of the RCA. Identify the contributing factors to the incident.
Include a Cause & Effect Diagram (Fishbone Diagram) to illustrate the contributing factors to the adverse event Include the Fishbone Diagram as an embedded image or appendix in your paper.
Fishbone Diagram Template
APA format with a title page.
This paper will automatically be submitted to Turnitin (plagiarism protection software), you may view the Turnitin results by clicking on the colored icon next to your assignment.
*This is my adverse event*: In my workplace, I experienced an adverse case of a patient who suffered from an episode of unconsciousness upon standing up post dialysis treatment. Patient sustained a fall forward to the floor and obtained a deep laceration to his forehead. As a nurse, I used my knowledge by making sure the patient is safe while lying on the floor and pressure was applied immediately to the area to stop the bleeding. 911 was called and needles were removed safely, and hemostasis achieved at the access site. All protocol was followed and patient was transferred to the nearest hospital. The patient was able to share relevant information after the fact, which helped us get a better understanding of what was happening to him prior to the event.
*See files below for fishbone template*

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