You have completed Assignment 1. This Assignment is the second part of Assignment 1. Please use the following elements in order to present a RCA (Root Cause Analysis), and/or a FMEA (Failure Mode and Effects Analysis) for your chosen Healthcare Clinical Practice Setting where, in Assignment 1, you have defined the:

1. Location and Name of the practice setting.

2. Patient population in the area of the practice setting.

3. The three predominant diagnoses/problems of the patients/clients in the practice setting.

4. The categories/professions/occupations of the staff in the practice setting.

5. The primary responsibilities of each category of staff.

6. One Adverse Event/Incident that has occurred/may occur.

It must be course related. Examples are an Infection/Infectious outbreak, or a systemic and serious safety condition, such a high number of staff/patient exposures to blood or air borne pathogens. This is the Sentinel Event.

Now, pretend you are the Director of Risk Management. A serious Adverse Event (Sentinel Event) related to an infectious process happened under your watch in your facility. You identified this Adverse Event in Assignment 1
(however, you may replace it or modify it if you want). Include in this paper:

1. The CEO of the Practice Setting.

2. Staff (such as MD, OT, PT, RN, NP or PA) involved in the Sentinel Event.

3. The Director of that Staff’s Practice Setting.

4. The outside Regulatory person (such as from the Department of Health, The Joint Commission, OSHA or FMEA) who is there to investigate, and make sure there is a process to deal with the Sentinel Event.

5. A patient representative, and/or other staff if you want. 


1. Identify any breach of practice, knowledge deficit, failure to follow standards such as universal or standard precautions or breach of regulatory and/or professional/institutional standards/policies/procedures that led to your Adverse Event (your infectious process).

2. Discuss what happened—the “who, what, when, where, why and how.”

3. Then, cite the correct process or processes using class related material.

4. Then present a corrective action plan using FOCUS, and finish with a Policy/Procedure and an Education Plan and a PDCA Quality Improvement/ Assurance/Performance (monitoring) Plan. 

(Key concepts to include in you paper:

1. Infection Control/Universal and Standard Precautions.

2. RCA – Root Cause Analysis

3. FMEA – Failure Mode and Effects Analysis

4. Quality Improvement/Assurance or Performance Improvement.

5. FOCUS and PDCA – Please research the meaning.

6. SBAR – Situation-Background-Analysis and Recommendation.

7. Time Out.

8. Sentinel Event)

9. Use new terminology used in the course.

Please reference resource material such as The Joint Commission, New York State Department of Health, the CDC, or other governmental, and other for profit or not for profit organizations.

Submit this Assignment (@ 5 pages) in appropriate academic format citing references.

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