Root Cause Analysis Root cause analysis (RCA) is a process in which the healthcare providers retrospectively study the past events with adverse outcomes for patients’ health (“Patient safety essentials toolkit,” n.d.). It is done to determine the root cause of these events to prevent them from happening again in the future medical care. The importance of this analysis should not be underestimated, as critical analysis is essential for achieving better patient outcomes. Root Cause Analysis Process Institute for Healthcare Improvement (IHI) describes six steps to conduct an RCA (“Patient safety essentials toolkit,” n.d.):  1. Identify what events.  2. Determine what should have happened instead.  3. Recognize the causes.  4. Create casual statements.  5. Think how to avoid reoccurrence of the events.  6. Make a summary of the analysis. These six steps allow the medical staff to recognize the issues that caused the negative outcome and find a path to avoid repeating the mistakes in the future. Root Cause Analysis Application to the Scenario According to the Root Cause Analysis, firstly the event should be defined – Mr. B was admitted to an ED due to severe pain in his leg and hip area. Then, the clauses should be clarified – he had fallen, tripping over the dog. The patient was admitted by Nurse J and Dr. T in case of finding the possible solutions, and he ordered the administration of sedative to process with manual hip manipulation. The actions were taken and then after verifying the solution ineffectiveness, more sedative was administrated when the first dosage did not work. According to the analysis, it should be started from the beginning in case of repeated attempt to figure out the root cause and another solution. After a short period, Mr. B’s son alerted them of alarming vitals. The patient did not respond to stimuli, and no palpable pulse could be detected. Mr. B was transported to a tertiary facility for advanced care, where seven days after EEG determined brain death and Mr. B was taken off life support. Process Improvement Plan The medical staff should be trained to keep an eye on patients under heavy sedation and supply them with oxygen, especially when the hospital does not experience a staff shortage. Medical staff should check the blood pressure, oxygen, and other vitals regularly, and the sedation should be administrated with more care. Additional or repeated sedation training modules might be necessary for the staff. Lewin’s Change Theory The first stage of Lewin’s change theory is known as unfreezing: in this scenario, additional training for the personnel, using similar examples, would be needed to change the way they view similar situations (“Lewin’s change theory,” 2020). The second stage, change, would require the hospitals to implement more strict regulations regarding sedation of patients and the care during the recovery. Finally, the refreezing stage would mean establishing the new process as the norm for the staff. Failure Mode and Effects Analysis Failure Modes and Effects Analysis (FMEA) is utilized to evaluate a process and see where it may fail and lead to negative patient outcomes or harm (“Failure modes and effects analys