| Course | NURS 4106 Patient Safety and Quality Improvement |
|---|---|
| Week | Week 4 |
| Paper type | Contributing factor analysis |
| Length | About 530 words, 4 pages |
| Format | APA 7 student paper |
| School | Walden University |
| Program | Bachelor of Science in Nursing (BSN) |
| Updated | October 2026 |
Free sample paper for NURS 4106 Week 4
Contributing Factor Analysis: A Heel Pressure Injury Found on Day Six of a Step-Down Stay
Student Name
College of Nursing, Walden University
NURS 4106: Patient Safety and Quality Improvement
Instructor Name
Month Day, Year
Contributing Factor Analysis: A Heel Pressure Injury Found on Day Six of a Step-Down Stay
The Event
A composite 78-year-old man with heart failure and type 2 diabetes was admitted to a step-down unit for fluid overload and started on high-dose intravenous diuretics. On day 6, during a bath, a nurse found a 3 cm area of intact, deep purple discoloration on the right heel, consistent with a deep tissue pressure injury under the staging system of the National Pressure Injury Advisory Panel (Edsberg et al., 2016). His admission skin assessment had documented intact heels. His Braden score on admission was 15 and had not been recalculated.
Contributing Factors by Category
The factors are sorted with a framework for analyzing clinical incidents whose categories run outward from the patient, through the task and its equipment, the individual nurse, the team, and the work environment, to the organization itself, so the analysis looks beyond the bedside (Vincent et al., 1998).
Table 1
Contributing Factors to the Heel Pressure Injury
| Category | Contributing factor |
|---|---|
| Patient | Diabetes with reduced sensation in the feet; poor perfusion from heart failure; fluid shifts; reluctance to move because of breathlessness |
| Task and technology | Heels rested on a standard mattress; no heel offloading boots on the unit's supply list; skin assessment field in the record copied forward on days 2 through 5 |
| Individual staff | Heels not inspected on days 2 to 5 because the patient was wearing socks; turning documented but heel position not |
| Team | Night staff turned the patient every 2 hours, but day staff assumed he was repositioning himself when awake |
| Work environment | Unit census at capacity for 4 days; frequent diuresis-related toileting took aide time |
| Organizational | Wound care nurse consults triggered only by an existing wound, not by a Braden score of 15 or lower; no policy requiring Braden recalculation after a change in condition |
How the Defenses Lined Up
No single failure caused the injury. The patient's diabetes and poor perfusion made his heels vulnerable. The mattress and the absence of offloading devices removed one defense. The copied-forward skin assessment and the socks removed another, because nobody looked. The team's split assumptions about repositioning meant daytime turning did not happen reliably. And the organization's consult rules meant no wound specialist was alerted by his risk score. This is the pattern described in the systems model of error, in which each layer of protection has gaps, and harm reaches the patient only when the gaps in several layers happen to align (Reason, 2000). Any one layer working would likely have prevented or caught the injury earlier.
Where to Intervene
The factors point to changes at more than one level. At the task level, heel offloading boots should be stocked and applied for any patient with a Braden score of 18 or lower. At the individual level, skin checks should include removing socks and should not be copied forward. At the organizational level, a Braden score at or below a set threshold should trigger a wound care nurse review automatically, and the Braden score should be recalculated with any significant change in condition. Changes at the organizational level are the most durable, because they do not depend on any one nurse remembering.
References
Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy and Continence Nursing, 43(6), 585-597. https://doi.org/10.1097/WON.0000000000000281
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Vincent, C., Taylor-Adams, S., & Stanhope, N. (1998). Framework for analysing risk and safety in clinical medicine. BMJ, 316(7138), 1154-1157. https://doi.org/10.1136/bmj.316.7138.1154
What the NURS 4106 Week 4 instructions ask for
The fourth NURS 4106 week commonly asks for an analysis of factors contributing to a safety event. You describe the event, sort factors into categories, show how defenses failed together and identify where to intervene. Faculty look for system thinking and penalize conclusions that blame an individual. Cite a contributing factor framework and staging guidance in APA 7. A fishbone diagram is common, with categories such as patient, task, team, environment and organization. Individual actions may be mentioned as part of system conditions. The analysis is close to a root cause analysis but may be simpler. NURS 4106 faculty want each category filled with at least one factor from the case. Show the defenses as layers with their gaps.
How the NURS 4106 Week 4 example is put together
Four pages plus a one-page fishbone diagram. The event summary opens the body in six neutral sentences: admission, transfer between units, the risk reassessment that did not occur after transfer, a specialty surface ordered and delivered late, a handoff that omitted a skin finding, and discovery on day six. The diagram groups contributing factors under six labeled spines: patient, task, equipment, environment, team communication and organization. Each spine then receives its own section of prose explaining the factors on it. A Swiss cheese paragraph follows, identifying which layers of defense had holes and how they aligned. The analysis closes by ranking three factors as most modifiable, which hands the intervention stage a clear starting point. Individual performance appears only inside its system context.
NURS 4106 Week 4 rubric: what earns full marks
Cause-analysis rubrics look first for system thinking, and they penalize analyses that conclude with a person. A finding that the nurse failed to turn the patient, however accurate as a description, sits in the lower bands because it names a behavior without explaining it. The sample's categories and alignment paragraph speak to that expectation directly. Organization carries real weight at this stage: labeled sections matching the diagram make the logic easy to follow and are often scored as a separate row. Depth is judged by whether each category holds factors that are specific and connected to the event, rather than generic entries like poor communication. The prioritization paragraph links forward to the intervention stage, which many instructors reward as coherence across the project. Evidence behind each factor still needs citation.
NURS 4106 Week 4 help from the desk
Cause analyses lose the most when they conclude the nurse failed to turn the patient. Ask why the system allowed it. Another common gap is listing factors without categories. Use a framework. Writers also skip how defenses lined up. Show the holes in each layer. Avoid naming staff. Stage the injury correctly with NPIAP terms. Include equipment availability. Close with the intervention point that would block the most holes. Writers also forget the diuretic's effect on toileting and moisture, a real contributor. Include it. Another frequent slip is an intervention aimed at one nurse. Aim it at the system, such as a reassessment prompt. Check the staging terms. Keep the timeline consistent.
Get a NURS 4106 Week 4 example written to your instructions
Name the event or rate your project tracks and attach the stage template with its rubric. A custom contributing factor analysis comes back in 24-48h, the first one free, with the fishbone drawn as an editable figure and each spine's label matching a section heading in the text.
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NURS 4106 Week 4 questions, answered
Is this just a root cause analysis under another name?
They overlap, and some courses use the terms interchangeably. A formal root cause analysis follows a specific organizational process with a team and an action plan. A contributing factor analysis in a course stage applies the same systems thinking in writing, usually with a fishbone or similar tool. The sample uses the broader label because it identifies several interacting factors rather than a single root.
Which categories should the fishbone use?
The categories your template or readings specify. Common sets include people, methods, equipment, environment and materials, or health care adaptations like patient, task, team and organization. The sample uses six health care categories because they fit the event well. Consistent labels between the diagram and the text matter more than which particular set is chosen.
Can the analysis mention individual errors at all?
Yes, when they are placed inside system context. The sample acknowledges that a reassessment did not happen, then asks what made it unlikely: a transfer process with no prompt and a workload peak at the time. Omitting individual actions entirely can make an analysis seem evasive. Explaining them through system conditions is what the rubric's system-thinking row rewards.
Where can I find a free NURS 4106 Week 4 sample paper?
The heel pressure injury analysis is printed here with the event, factors by category, the Swiss cheese alignment and where to intervene.
What injury does NURS 4106 Week 4 analyze?
A heel pressure injury found on day 6 of a step-down stay in a man on high-dose diuretics.