NURS-FPX4035 Assessment 2: Root-Cause Analysis and Safety Improvement Plan Sample

Enhancing Patient Safety and Quality of Care · Assessment 2 · Root-Cause Analysis and Safety Improvement Plan

Assessment
Assessment 2
Course code
NURS-FPX4035
Course
Enhancing Patient Safety and Quality of Care
Degree/program
BSN
Analytical Tools Used
Chronological event review, five-whys analysis, and contributing-factor matrix
Clinical Focus
SAFE Toileting and Mobility Bundle for inpatient fall prevention
Patient Case Details
78-year-old female with weakness, urinary urgency, prior fall history, and changing cognition
Deliverable Format
Root-cause analysis template and 4-6 page safety improvement plan
Prepared by: FlexPath Assignment Help Editorial Team · Course reviewed by: Senior Nursing Academic Content Reviewer · Last reviewed: August 14, 2026

About NURS-FPX4035 Assessment 2

This NURS-FPX4035 Assessment 2 sample models a root-cause analysis and safety improvement plan for a fictional inpatient fall. It reconstructs the event, examines patient, workflow, communication, and environmental contributors, and connects the findings to a feasible fall-prevention plan, organizational resources, and measures.

Course context: view the NURS-FPX4035 course hub for the course overview and published assessments.

Root-Cause Analysis and Improvement-Plan Structure

This sample systematically evaluates a sentinel event and proposes actionable systemic improvements. It is organized around the following sections:

  1. Event Chronology and Immediate Response: Reconstructs the timeline from the evening handoff at 18:45 to the unassisted fall at 02:15, isolating missed clinical risks and removed defenses.

  2. Root-Cause Analysis (Five-Whys): Connects the immediate cause (unassisted transfer) to the root system failure (treating fall prevention as a generic score rather than an individualized plan).

  3. Contributing Factors Matrix: Rates the relative contribution of dynamic clinical risks, missing reassessments, alarm/call-light failures, and workload variables.

  4. SAFE Toileting and Mobility Improvement Plan: Outlines six core actions: Screen and reassess, align tailored bedside plans, facilitate safe mobility, engage patient/family, communicate/escalate, and learn from events.

  5. Implementation, Measurement, and Sustainability: Details a four-phase rollout plan over six months and establishes strict metrics to prevent the reduction of falls from overloading staff or restricting mobility.

Patient Fall Root-Cause Analysis and Evidence-Based Safety Strategies

Fishbone root-cause analysis and fall-prevention safety improvement plan for NURS-FPX4035 Assessment 2.

Root-Cause Analysis and Planning Steps

Use these steps to review the sample and plan an original root-cause analysis:

  • Analyze the root causes of a specific safety event by establishing a detailed event chronology and utilizing a five-whys inquiry.

  • Identify the specific human, process, communication, and environmental factors contributing to the event using a contributing-factor matrix.

  • Apply best-practice, evidence-based strategies—such as the Fall TIPS toolkit and TeamSTEPPS communication frameworks—to address the identified system failures.

  • Create a feasible, multiphase improvement plan that names specific owners, targets, and execution steps (e.g., a 30-day preparation phase and a 60-day pilot on 8 beds).

  • Leverage existing organizational resources, prioritizing tools like the electronic health record (EHR) and incident-reporting systems for maximum impact.

  • Define precise outcome measures (e.g., a 30% reduction in total falls), process measures (e.g., teach-back success), and balancing measures (e.g., staff overtime).

  • Assessment hierarchy

    Supporting guides for evidence and implementation

    Use these guides to check the connection among the event chronology, root-cause findings, selected evidence, improvement actions, organizational resources, and measures. Compare the completed work with the current course instructions and scoring guide before submission.

    Frequently asked questions

    What does this NURS-FPX4035 Assessment 2 sample demonstrate?

    It demonstrates an event chronology, five-whys inquiry, contributing-factor analysis, and a safety improvement plan for a fictional inpatient fall.

    How do the chronology and root-cause analysis work together?

    The chronology establishes what happened and when. The root-cause analysis then examines why safeguards failed across patient, task, communication, staffing, equipment, and environmental conditions.

    What makes the improvement plan measurable?

    Connect each action to an owner, implementation step, organizational resource, and suitable outcome, process, or balancing measure. Use targets only when they are supported by the scenario or current instructions.

    Can I submit this sample as my own assessment?

    No. Use it only as a learning model. Develop an original safety case and analysis, select appropriate evidence, cite borrowed ideas, and follow the current courseroom instructions and scoring guide.

    Study and academic-use guidance

    Use this sample to study structure, evidence relationships, analytical sequencing, and scoring-guide alignment. Build your own response from the current courseroom requirements.

    • Verify the current instructions, template, evidence requirements, and scoring guide.
    • Create your own analysis, calculations, visuals, citations, and conclusions.
    • Check factual, clinical, legal, numerical, and source claims before submission.

    Independent resource: FlexPath Assignment Help is not affiliated with or endorsed by Capella University. Do not submit sample wording or analysis as your own work.

    Other NURS-FPX4035 assessments

    NURS-FPX4035 Assessment 1: Enhancing Quality and Safety Sample
    Assessment 1 · PDF available
    NURS-FPX4035 Assessment 3: Improvement Plan In-Service Presentation Sample
    Assessment 3 · PDF available
    NURS-FPX4035 Assessment 4: Improvement Plan Tool Kit Sample
    Assessment 4 · PDF available