Identify the root causes of nursing practice breakdown from individual persons and systems causes.

Identify the root causes of nursing practice breakdown from individual persons and systems causes.

Create a Fishbone analysis; A Quality Improvement tool to showing major causes of an event that led to effect (outcome). A fishbone helps to fully analyze a problem in order to determine the best solutions. Fishbone Diagram Using the 5 Whys technique- include at least 4 spines of fishbone (2 individual Nurse practice issues and 2 system issues- that correlate, so in actuality the student would only need to think of two topics or causes and look at them from nurse individual and system breakdowns) (using TERCAP ,2013 {Taxonomy of Error; Root Cause Analysis; and Practice Responsibility} an initiative of the National Council of State Boards of Nursing) it is a national nursing adverse event database designed to collect practice breakdown data to identify the root causes of nursing practice breakdown from individual persons and systems causes. The categories would include: (5 points ) 1. Nurse characteristics, 2. Patient characteristics, 3. System factors and 4. Practice breakdowns. Incorporates outline topics (from annotated bib) into Fishbone Diagram 5 (15 points) Creates at least 3 categories/causes under each spine topic for a total of at least 12 topics(causes) resulting in the overall effect/outcome) (30 Points) Overall Appearance: Fishbone is visually appealing and inviting refer to model in powerpoint (5points) Proper APA formatting of cause with citations. No spelling or grammar errors. Add an additional page containing APA references. Needs to be turned in to the drop box with Fishbone diagram. (5points) Total (60 points )

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