1. Using A Senior Capstone Project to Link Root Cause Analysis to the Practice Realm
Mikel W. Hand, EdD, RN, OCN, NE-BC, NEA-BC, Assistant Professor of Nursing
Susan Seibert, MSN, RN, Clinical Assistant Professor of Nursing
University of Southern Indiana College of Nursing & Health Professions
Student Power Point Slide:
Results
Project
Development of a senior capstone project to engage students in Root Cause Analysis (RCA)
Setting: BSN Leadership and Management Course in both the traditional prelicensure BSN and RN to BSN completion program.
Project successfully implemented in 3 consecutive courses
Sample topics:
Organ transplantation error
Death after central line removal
Heparin overdose
Death by PCA overdose
Student feedback concerning the overall learning experience very positive.
“The RCA project also makes students more aware of some inherent risks in providing patient care and will hopefully help make us more conscientious practitioners in the future. ”
Christina Samuels, USI Student
Theoretical Framework
Instructional Design
Problem –based learning
RCA is complex and challenging
Cases used are real
Students engage as collaborative teams to examine the case and apply RCA principles
Motivation to address the case using RCA becomes the motivation to learn
Teams of students select instances of significant medical error from media to complete the following assignment criteria:
Research the case
Identify potential members of RCA team
Interview individuals in local hospitals regarding topic (QI team leader, nurse attorney, nurse manager, pharmacist, surgeon).
Integrate evidence from literature
Formulate a RCA based on available information
Submit a formal paper including recommendations for system and process improvements
Present project to classmates (oral presentation) either in class (traditional) or online (RN to BSN) using Voice Thread technology.
Implications for Practice
Actively engages students in RCA using actual cases from literature and the media
Empowers students with knowledge and skills of QI processes
Prepares students for involvement in QI even as new graduates
RCA