NURS 6223 Week 3 Root Cause Analysis Example

Course	NURS 6223 Healthcare Quality Assurance and Risk Management in Healthcare Organizations
Week	Week 3
Paper type	Root cause analysis
Length	About 770 words, 5 pages
Format	APA 7 student paper
School	Walden University
Program	Master of Science in Nursing (MSN)
Updated	October 2026

Free sample paper for NURS 6223 Week 3

Root Cause Analysis: Delayed Escalation of a Rising Early Warning Score

Student Name

College of Nursing, Walden University

NURS 6223: Healthcare Quality Assurance and Risk Management in Healthcare Organizations

Instructor Name

Month Day, Year

What this page is doingThe analysis begins with the explanation it ends up rejecting, a nurse who did not call, and follows the why-questions to conditions the organization controls.

Root Cause Analysis: Delayed Escalation of a Rising Early Warning Score

Summary

Over about three hours one night, the early warning score of an adult medical patient being treated for pneumonia climbed from 5 to 7, and it took a respiratory arrest to prompt the first rapid response call. The patient survived after intubation and intensive care. The event was classified as severe harm and screened in as a potential sentinel event. The review followed the RCA2 approach, which aims to identify system vulnerabilities and to favor actions that change systems over actions that depend on individual vigilance (National Patient Safety Foundation, 2015).

Review Team

The team was led by a nurse manager from the surgical service, outside the unit, and included a staff nurse from another medical unit, a hospitalist not involved in the event, a rapid response nurse, a clinical informatics nurse and a patient safety specialist. The three clinicians involved that night were interviewed but did not sit on the team.

Causal Analysis

The tree runs downward from the outcome. The first answer to why escalation was delayed, that the night nurse did not call, was where the team began, not where it stopped. Each branch continued until it reached a condition the organization controls.

Why was the rapid response team not called at a score of 5 or 7? Because the calling criteria allowed, rather than required, a call at those scores, leaving the decision to nurse judgment. Why did judgment favor waiting? Because the protocol described calling the covering provider first, and the provider had been paged. Why was the provider slow to respond? Because one hospitalist covered three medical units overnight and was managing an emergency on another unit.

Why was the rise from 5 to 7 not seen sooner? Because the score was calculated by hand at the end of each vital signs round, not with each set of vital signs, so the recheck at 190 minutes was the first time the higher score existed. Why is the score calculated by hand? Because the electronic record displays vital signs but does not calculate or alert on the score.

Why did the charge nurse advise waiting? Because the charge nurse was covering an admission and relied on the bedside nurse's summary, and no unit expectation defined when a charge nurse should call on the nurse's behalf.

Causal Statements

1. Calling criteria that permit rather than require a rapid response call at an elevated score increased the likelihood that escalation would be deferred to a busy covering provider, which delayed rapid response assessment.

2. Manual calculation of the early warning score at the end of each round increased the time between physiological deterioration and a documented score, which delayed recognition of the rising score.

3. Overnight coverage of three units by one hospitalist increased the likelihood of delayed provider response to pages, which extended the period before any clinician assessed the patient.

4. The absence of a defined charge nurse role in escalation increased reliance on individual bedside judgment, which removed a second check on the decision to wait.

What this page is doingEach statement links a system condition to an effect and to the outcome, without describing any individual as careless.

Action Plan

Actions are sorted by strength using the RCA2 hierarchy, in which stronger actions change the system itself, intermediate actions add checks or redistribute work, and weaker actions depend on training and policy alone (National Patient Safety Foundation, 2015).

Table 1

Actions by Strength, Owner and Measure

Action	Strength	Accountable role	Measure
Electronic record calculates the score with every set of vital signs and pages the rapid response nurse directly at a set threshold	Stronger	Director of clinical informatics	Share of qualifying scores that generate a page
Calling criteria changed so a score above threshold requires a rapid response call regardless of other pages	Stronger	Chair, resuscitation committee	Time from qualifying score to rapid response arrival
Overnight coverage adjusted so no hospitalist covers more than two medical units	Intermediate	Chief medical officer	Median page response time overnight
Charge nurse escalation expectation added to the role	Intermediate	Director of medical nursing	Audit of charge nurse involvement in qualifying cases
Education on early warning scores for medical unit staff	Weaker	Unit educator	Completion rate

The strongest action has evidence behind it: in a before-and-after controlled trial across twelve general wards, electronic devices that automated vital sign capture and early warning score calculation were associated with more rapid response calls triggered by respiratory abnormalities and improved survival after those calls (Bellomo et al., 2012). Known barriers to calling, including uncertainty about criteria and hesitation to bypass the usual chain of escalation (Chua et al., 2017), are the reason the calling criteria are changed rather than simply retaught.

References

Bellomo, R., Ackerman, M., Bailey, M., Beale, R., Clancy, G., Danesh, V., Hvarfner, A., Jimenez, E., Konrad, D., Lecardo, M., Pattee, K. S., Ritchie, J., Sherman, K., & Tangkau, P. (2012). A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards. Critical Care Medicine, 40(8), 2349-2361. https://doi.org/10.1097/CCM.0b013e318255d9a0

Chua, W. L., See, M. T. A., Legido-Quigley, H., Jones, D., Tee, A., & Liaw, S. Y. (2017). Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: A systematic review. International Journal for Quality in Health Care, 29(8), 981-998. https://doi.org/10.1093/intqhc/mzx149

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm.

NURS 6223 Week 3 instructions, in plain terms

In the third NURS 6223 week, students usually analyze why one adverse event happened, using root cause methods. You form a team, analyze causes with a structured method, write causal statements and propose an action plan ranked by strength. Faculty measure whether the analysis reaches system causes rather than stopping at an individual. Cite RCA2 and clinical evidence in APA 7. RCA2 adds an emphasis on stronger actions and causal statements that follow set rules. Each why chain should go until it reaches something the organization controls. Training can appear in the action plan, but only beside stronger fixes. A clean format moves from summary, to team, to analysis, to statements, to actions.

Inside the NURS 6223 Week 3 example

Four pages under the headings most templates use. A one-paragraph summary carries the classification forward from the prior analysis. The review team is listed by discipline and led by a manager from outside the unit. The causal section is a tree drawn from the outcome downward through repeated why-questions, and each branch stops only where it reaches a condition the organization controls: an early warning score calculated by hand at the end of a vital signs round, pages routed to a covering provider responsible for three units, and calling criteria that left the rapid response call to nurse discretion. Four causal statements summarize the tree. An action table follows, sorting each action as stronger, intermediate or weaker in RCA2's terms, with the accountable role and the measure listed beside it.

Reading the NURS 6223 Week 3 rubric

Depth past the first explanation is what this week measures, and the quickest way to show its absence is an analysis ending at the night nurse. Criteria in most sections look for causes an organization can act on, so a tree whose branches end in inattention collects little analytic credit however long it runs. The sample's stopping rule answers that directly. Action strength is increasingly assessed as an item of its own: a plan whose strongest entry is education signals that the review found nothing to redesign. Instructors also read for alignment, and an action that no branch supports costs credit even when the action itself is sensible. Omitting the team composition is a small deduction but a frequent one. Measures attached to only some actions leave the table half-built, and markers notice which rows were skipped.

Common NURS 6223 Week 3 mistakes, and how to avoid them

Root cause analyses lose credit when they end at the nurse who did not call. Ask why again. Another common gap is causal statements that blame. Use the RCA2 rules. Writers also propose only education. Add stronger actions, such as automated alerts. Avoid an action plan with no owner or date. Assign each. Name the team by role. Rank actions by strength so the reader sees which ones change the system. A measure for each action shows how you will know it worked. Close with the strongest action and why.

Get a NURS 6223 Week 3 example written to your instructions

Attach the Week 3 prompt, the rubric and the event from your earlier analysis, or request a composite event if you are starting fresh this week. Within 24-48h the RCA arrives, the first free, its action table sorted by strength, its causal tree ready to redraw in your own template and every branch numbered.

More NURS 6223 papers and MSN samples

NURS 6223 Week 3 questions, answered

What does RCA2 add to a standard root cause analysis?

Two emphases that show up in the finished document. RCA2, the framework the National Patient Safety Foundation published and IHI now carries, stresses review teams that include people outside the event and actions ranked by strength, so that redesign is preferred to retraining. The sample shows both, in its team list and in its sorted action table. The underlying causal reasoning is the same as in any careful analysis.

How far down should each why-chain go?

To a condition the organization could change, and no further. Stopping earlier leaves a person as the cause; going further tends to reach conditions such as the regional supply of nurses, which no action plan here can touch. The sample's chains end at the score calculation, the paging arrangement and the calling criteria. Asking why five times is a common rule of thumb, but the stopping point matters more than the count.

Can training appear in the action plan at all?

Yes, as a supporting action. RCA2 classes training and new policy as weaker because they rely on memory and attention, the same resources that were strained when the event happened. The sample keeps a reeducation session in the plan to accompany the automated score and the revised calling criteria rather than stand in for them. A plan resting on training alone suggests the analysis stopped before it found anything structural.

Where can I find a free NURS 6223 Week 3 sample paper?

The delayed escalation root cause analysis is printed here with the team, the causal chains, RCA2 causal statements and the ranked action plan.

What actions does the NURS 6223 Week 3 plan favor?

Stronger fixes such as automated score calculation and alerts, ranked above training and policy reminders.