RCA, FMEA, and Change Theory in ED Patient Safety
This paper applies root cause analysis (RCA), change theory, and failure mode and effects analysis (FMEA) to a case study involving the death of a patient, referred to as Mr. B, in an emergency department setting. Using the RCA framework endorsed by the U.S. Department of Health and Human Services, the paper identifies systemic errors including inadequate nursing staffing, misdiagnosis, and inappropriate pain management. Kurt Lewin's change theory is then used to organize driving and restraining forces for improvement. A seven-step FMEA protocol is outlined to prioritize and address these hazards. The paper concludes by emphasizing the essential role nurses play in centering patient care over institutional pressures.
- Introduction to Root Cause Analysis: RCA defined and applied to adverse healthcare events
- Errors Identified in the Case: Systematic errors in Mr. B's emergency care
- Improvement Plan Using Change Theory: Lewin's forces applied to ED improvement
- Failure Mode and Effects Analysis (FMEA): Seven-step FMEA protocol for ED safety
- The Role of Nurses in Patient Safety: Nurses as patient advocates amid profit pressures
- Conclusion: Care and healing as core nursing obligations
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What makes this paper effective
- Applies three distinct analytical frameworks (RCA, change theory, FMEA) in sequence, giving the paper a clear, cumulative structure that builds toward a practical improvement plan.
- Uses the simple but powerful "Why?" questioning technique of RCA to make the error identification section accessible and logically grounded.
- Grounds Lewin's abstract change theory in the concrete details of the case by sorting specific factors — such as malpractice law, staffing shortages, and drug abuse — into driving and restraining forces.
Key academic technique demonstrated
The paper demonstrates applied framework analysis: it takes established theoretical and procedural models (RCA, Lewin's force field analysis, FMEA) and systematically applies each to the same real-world case. This technique allows the writer to examine the same problem from multiple analytical angles, which is a common and expected approach in healthcare quality improvement writing.
Structure breakdown
The paper opens by defining RCA and situating it within a healthcare quality context, then moves into error identification via iterative "Why?" questions. It transitions to Lewin's three-force change model and maps case-specific factors onto it, followed by a step-by-step FMEA protocol. The paper closes with a brief normative argument about the centrality of nursing care. Each section is clearly delineated, making the progression from diagnosis to improvement plan easy to follow.
Introduction to Root Cause Analysis
Root cause analysis (RCA) is a systematic approach designed to simplify complex problems and guide investigators — like a trail of clues — toward objective truths, or at least well-supported conclusions. The U.S. Department of Health and Human Services endorsed this method as a practical approach through its Agency for Healthcare Research and Quality. The agency acknowledged that "root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals."
This essay addresses the case study of Mr. B's untimely death and applies an RCA to the facts of the case. It also uses change theory to develop an improvement plan aimed at decreasing the likelihood of similar events occurring in the future. Additionally, a failure mode and effects analysis (FMEA) is used to project the likelihood of failure in response to proposed system changes. Finally, the role of nurses and the critical importance of their caring function to any patient's odds of survival is examined throughout.
References
Burnes, B. (2004). Kurt Lewin and complexity theories: back to the future? Journal of Change Management, 4(4), 309–325.
Eriksson, K. (1996). Understanding the world of the patient, the suffering human being: The new clinical paradigm from nursing to caring. Advanced Practice Nursing Quarterly, 3(1), 8–13.
Riehle, M. A., Bergeron, D., & Hyrkas, K. (2008). Improving process while changing practice: FMEA and medication administration. Nursing Management, 39(2), 28–33.
U.S. Department of Health and Human Services (n.d.). Agency for Healthcare Research and Quality. Root cause analysis. Retrieved from
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