RCA Root Cause Analysis and Action Plan grid

From a systems thinking approach, conduct an RCA for this case using the attached Root Cause Analysis and Action Plan grid.  For this assignment, you will read the case (Attached) and conduct an RCA. Detailed instructions are provided after the case.  

The goal of RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events (Agency for Healthcare Research and Quality, 2017, June). 

From a systems thinking approach, conduct an RCA for this case using the attached Root Cause Analysis and Action Plan grid. For this assignment, you will analyze the sequence of events leading to the error to identify how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors). From there, develop an action plan to be put in place to prevent such an event from occurring in the future.

Length: 3–4 pages

References: Include a minimum of 3 peer-reviewed, scholarly resources.

Your assignment should demonstrate thoughtful consideration of the ideas and concepts that are presented in the course and provide new thoughts and insights relating directly to this topic. Your assignment should also reflect graduate-level writing and APA standards (6th ed.). Be sure to adhere to write on a Doctoral Level.