A patient who underwent open heart surgery died two days later due to septicemia. Which quality-improvement tool would the nurse use to determine the underlying cause of the death?

• A. Root cause analysis (RCA)
• B. Plan-Do-Study-Act (PDSA)
• C. Failure mode effects analysis (FMEA)
• D. Computerized physician order entry (CPOE)

Answer: (A)

Root cause analysis is the method used after a sentinel event, like a death following surgery, to uncover the underlying system and process factors that contributed to the outcome. It goes beyond blaming individuals and looks at what happened across the care continuum—preop, intraop, and postoperative steps, infection control practices, line care, antibiotic timing, and monitoring—so the team can identify contributing factors and implement changes to prevent recurrence. This collaborative, retrospective investigation aims to pinpoint root causes and develop corrective actions, such as protocol updates or staff education.

The other options fit different purposes. Plan-Do-Study-Act is a cycle for testing and implementing small-scale improvements, not specifically for determining why an adverse event occurred. Failure mode effects analysis is a proactive tool to anticipate where failures could happen before they occur. Computerized physician order entry is a system to standardize orders and reduce errors, not an analysis method for determining the cause of death.