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

4. Practice breakdowns.

Incorporate outline topics (from annotated bib) into Fishbone Diagram 5 (15 points)

Create at least 3 categories/causes under each spine topic for a total of at least 12 topics(causes) resulting in the overall effect/outcome.

Proper APA formatting of cause with citations. No spelling or grammar errors. Add an additional page containing APA references.

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