Date of Graduation

Fall 12-14-2018

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Executive Leader DNP

First Advisor

Dr. Marjorie Barter

Second Advisor

Dr. Elena Capella


Problem: The subject organization (SO) is a Federally Qualified Health Center (FQHC) with an internally developed incident reporting system. The SO wanted to improve patient and employee safety using data from incident reports, but the incident reporting system did not give enough information to recognize patterns and develop countermeasures.

Context: Supervisors welcomed the opportunity to learn more about incident report follow-up and conducting root cause analysis (RCA). Members of the Safety Committee were eager for data to use to develop countermeasures to improve patient and employee safety. Decreases in employee injuries can save the SO from increases in the cost of worker’s compensation coverage, so the SO leadership supported the project. The organization is covered by the Federal Tort Claims Act (FTCA) for malpractice insurance, but there is always a cost to preparing a defense against claims, so the Chief Financial Officer was supportive of a project that could reduce the chance of claims.

Interventions: The project was conducted in three stages. The first stage was to design a data collection tool for supervisors to use to guide incident report follow-up and document RCA. The second stage was to conduct training sessions for supervisors to teach them about organizational fairness, using a human-factors approach to evaluate incidents, how to conduct an investigation, and how to perform RCA. The third step was to send the data collection tool to supervisors to collect additional information about incidents. The data were extracted from the completed tools and presented to the Safety Committee.

Measures: The project measured effectiveness of the class in increasing confidence with doing RCA and conducting IR follow-up. The project also measured the effectiveness of the class in training supervisors to use the data collection tool correctly. A third measure was whether the training and use of the tool improved the rate of RCA documentation in IRs when it was assigned to supervisors.

Results: The emphasis of the class training shifted due to the need to do remedial incident report training with the supervisors, therefore completion of the data collection tool was de-emphasized. Of the returned responses, most (95.7% for general incident and 98.4% for employee incident) respondents completed the section requesting an analysis of accident causes. Just over half of the respondents (54.3% and 51.6%) completed the analysis of workflow variance, and few (17.4% and 20.3%) provided a root cause. The comfort level with collecting additional information after an incident increased 24.9% and the agreement with understanding how to conduct RCA increased 46.5%. The completion rate of RCA documented in the IRs themselves increased slightly from 61.5% in the 24-week period before the intervention to 67.9% in 24-week intervention period.

Conclusions: While the project has not yet provided a direct benefit to the SO by producing countermeasures for incidents, the work done by the project lead and the Senior Vice President and General Counsel (SVPGC) will enable the SO to improve the incident reporting system. The project implies that more training is needed for supervisors to conduct follow-up investigations and to do RCA after an incident. The findings also imply that the organization needs to spread a culture of safety to all departments and to all levels. In addition to improving patient care by decreasing errors, establishing a culture of organizational fairness and safety may support other quality improvement efforts and help with employee retention.