Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide. You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect.

The rubric aspect titles may contain hyperlinks to relevant portions of the course.

A. Explain the general purpose of conducting a root cause analysis (RCA). 1. Explain each of the six steps used to conduct an RCA, as defined by IHI. 2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome. B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome. 1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan. C. Explain the general purpose of the failure mode and effects analysis (FMEA) process. 1. Describe the steps of the FMEA process as defined by IHI. 2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B. Note: You are not expected to carry out the full FMEA. D. Explain how you would test the interventions from the process improvement plan from part B to improve care. E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas: • 4 • improving patient outcomes • influencing quality improvement activities 1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities. F. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. G. Demonstrate professional communication in the content and presentation of your submission.