Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study
Abstract Background Sentinel events, involving serious injury or death, reveal critical vulnerabilities in clinical practices. Nurses play a key role in identifying errors and contributing factors in such events. However, evidence on the effectiveness of nurse-guided RCA in improving compliance and...
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BMC
2025-02-01
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| Series: | BMC Nursing |
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| Online Access: | https://doi.org/10.1186/s12912-025-02787-6 |
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| author | Li-Li Huang Yan-Hong Jiang Ju-Hong Yang Wei-Wen Hong Hai-Fei Chen Wei-Wei Hu |
| author_facet | Li-Li Huang Yan-Hong Jiang Ju-Hong Yang Wei-Wen Hong Hai-Fei Chen Wei-Wei Hu |
| author_sort | Li-Li Huang |
| collection | DOAJ |
| description | Abstract Background Sentinel events, involving serious injury or death, reveal critical vulnerabilities in clinical practices. Nurses play a key role in identifying errors and contributing factors in such events. However, evidence on the effectiveness of nurse-guided RCA in improving compliance and corrective actions is limited. Objective The aim of our research is to deeply explore the experiences, roles, challenges, and strategies of nurses in guiding RCA. By concentrating on nurses’ guidance, we can provide in-depth insights into their unique contributions in the RCA process. Methods Twelve participants from a tertiary hospital in southeastern mainland China were selected for the study. A constructivist qualitative research method was used to collect views and opinions from the participants' perspectives through semi-structured face-to-face interviews, and content analysis was applied, the data was further interpreted using thematic analysis. Results A total of 12 RCAdirectors were included in this study. Analyses revealed four main themes and 11 sub-themes. The main themes were: (1) success in a demanding field requires exceptional skills and abilities (having comprehensive knowledge, empowering capabilities, demonstrating interest and engagement), (2) building strong interpersonal relationships between guides and team leaders (selecting mature and experienced team leaders, building trust and cooperation with team leaders, exerting the guiding role of team leaders in projects), (3) tailored communication strategies in nursing for effective leadership and safety enhancement (navigating complex hierarchies through tailored communication, fostering collaboration through targeted communication strategies, empowering teams through clear and adapted communication) (4) investing effort and overcoming obstacles are key to successful nursing-guided project implementation (investing time and effort in project implementation, addressing obstacles during project advancement). Conclusion We provide new evidence on the critical role of the care coach in RCA programmes, highlighting the importance of competence, communication, trust and collaboration in enhancing team dynamics and improving quality of care and safety outcomes. |
| format | Article |
| id | doaj-art-eb43996d64024045a663947f53958256 |
| institution | Kabale University |
| issn | 1472-6955 |
| language | English |
| publishDate | 2025-02-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Nursing |
| spelling | doaj-art-eb43996d64024045a663947f539582562025-02-09T12:27:23ZengBMCBMC Nursing1472-69552025-02-0124111010.1186/s12912-025-02787-6Experience of nurse-guided root cause analysis after a sentinel event: a qualitative studyLi-Li Huang0Yan-Hong Jiang1Ju-Hong Yang2Wei-Wen Hong3Hai-Fei Chen4Wei-Wei Hu5Department of Quality Management, Huangyan Hospital Affiliated to Wenzhou Medical UniversityTaizhou First People’s HospitalDepartment of Outpatient, Taizhou First People’s HospitalInfusion Room, Taizhou First People’s HospitalDepartment of General Surgery, Huangyan Hospital of Traditional Chinese MedicineOperating Room, Taizhou First People’s HospitalDepartment of General Surgery, Taizhou First People’s HospitalAbstract Background Sentinel events, involving serious injury or death, reveal critical vulnerabilities in clinical practices. Nurses play a key role in identifying errors and contributing factors in such events. However, evidence on the effectiveness of nurse-guided RCA in improving compliance and corrective actions is limited. Objective The aim of our research is to deeply explore the experiences, roles, challenges, and strategies of nurses in guiding RCA. By concentrating on nurses’ guidance, we can provide in-depth insights into their unique contributions in the RCA process. Methods Twelve participants from a tertiary hospital in southeastern mainland China were selected for the study. A constructivist qualitative research method was used to collect views and opinions from the participants' perspectives through semi-structured face-to-face interviews, and content analysis was applied, the data was further interpreted using thematic analysis. Results A total of 12 RCAdirectors were included in this study. Analyses revealed four main themes and 11 sub-themes. The main themes were: (1) success in a demanding field requires exceptional skills and abilities (having comprehensive knowledge, empowering capabilities, demonstrating interest and engagement), (2) building strong interpersonal relationships between guides and team leaders (selecting mature and experienced team leaders, building trust and cooperation with team leaders, exerting the guiding role of team leaders in projects), (3) tailored communication strategies in nursing for effective leadership and safety enhancement (navigating complex hierarchies through tailored communication, fostering collaboration through targeted communication strategies, empowering teams through clear and adapted communication) (4) investing effort and overcoming obstacles are key to successful nursing-guided project implementation (investing time and effort in project implementation, addressing obstacles during project advancement). Conclusion We provide new evidence on the critical role of the care coach in RCA programmes, highlighting the importance of competence, communication, trust and collaboration in enhancing team dynamics and improving quality of care and safety outcomes.https://doi.org/10.1186/s12912-025-02787-6Sentinel eventGuideRoot Cause Analysis (RCA)Qualitative researchExperience |
| spellingShingle | Li-Li Huang Yan-Hong Jiang Ju-Hong Yang Wei-Wen Hong Hai-Fei Chen Wei-Wei Hu Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study BMC Nursing Sentinel event Guide Root Cause Analysis (RCA) Qualitative research Experience |
| title | Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study |
| title_full | Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study |
| title_fullStr | Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study |
| title_full_unstemmed | Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study |
| title_short | Experience of nurse-guided root cause analysis after a sentinel event: a qualitative study |
| title_sort | experience of nurse guided root cause analysis after a sentinel event a qualitative study |
| topic | Sentinel event Guide Root Cause Analysis (RCA) Qualitative research Experience |
| url | https://doi.org/10.1186/s12912-025-02787-6 |
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