| Course | EDN 812 Legal and Ethical Issues in Health Care Administration |
|---|---|
| Module | Module 6 |
| Paper type | Sentinel event root cause analysis |
| Length | About 1,480 words, 8 pages |
| Format | APA 7 student paper |
| School | Aspen University |
| Program | Doctor of Education |
| Updated | September 2026 |
Free sample paper for EDN 812 Module 6
The Wire That Stayed: Root Cause Analysis of a Retained Central Line Guidewire and the Actions That Followed
Student Name
Doctor of Education Program, Aspen University
EDN 812: Legal and Ethical Issues in Health Care Administration
Instructor Name
Month Day, Year
The Wire That Stayed: Root Cause Analysis of a Retained Central Line Guidewire and the Actions That Followed
At 2:15 on a Sunday morning in the medical ICU at Sable Creek Health, a second-year resident placed an internal jugular central venous catheter in a composite 61-year-old woman in septic shock. Her blood pressure fell during the procedure, the first catheter had to be repositioned over a second wire pass, and the bedside nurse stepped away to start a norepinephrine infusion. The catheter was sutured and dressed. The guidewire was still inside the patient. A chest radiograph taken an hour later was reported as showing the catheter tip in the superior vena cava, without mention of the wire. On the third day a radiologist reviewing a new film saw a long wire extending into the inferior vena cava, and interventional radiology removed it without lasting harm. This paper reports the root cause analysis and the action plan that followed.
Why This Is a Sentinel Event
The Joint Commission defines unintended retention of a foreign object after an invasive procedure as a sentinel event whether or not the patient is harmed, and it expects an accredited organization to finish a comprehensive systematic analysis, along with its plan of corrective actions, inside 45 business days of learning of the event. Sable Creek's own policy treats it the same way. The patient's good outcome was fortunate, not protective: a retained wire can cause perforation, thrombosis, arrhythmia or embolization, and the same failure next time may not be caught on the third day.
Method
The analysis followed the RCA2 guidance, which recommends a team of four to six members, including a front-line clinician and a patient safety specialist but no one directly involved in the event, beginning within 72 hours and focusing on actions strong enough to change the system (National Patient Safety Foundation, 2015). The team interviewed the resident, the nurse, the supervising attending, the teleradiologist and the charge nurse; walked through a simulated insertion with the same kit in the same room; reviewed the unit's staffing records for the night; and examined 12 months of central line insertions for near misses. The patient and her husband were told of the event within 24 hours and invited to share their account with the team.
What Happened
The timeline below was reconstructed from interviews, the electronic record, the dispensing cabinet log and the radiology system.
| Time | Event | What the team found |
|---|---|---|
| 01:40 | Patient hypotensive despite fluids; attending orders central line and vasopressors by phone | Attending at home, standard for the overnight model; no second physician in the unit |
| 02:05 | Resident begins ultrasound-guided insertion with one nurse assisting | Unit had one nurse short; charge nurse covering two patients |
| 02:20 | First catheter position questioned; wire reinserted and catheter repositioned | Second wire pass, a recognized risk scenario |
| 02:24 | Blood pressure falls to 68/40; nurse leaves the field to hang norepinephrine | No one left to watch the tray or call out the wire |
| 02:31 | Catheter sutured, dressed; kit discarded into sharps bin | Wire never returned to the tray; no step required it |
| 03:12 | Chest radiograph reported: tip in the superior vena cava | Report template asked only for tip position |
| Day 3, 10:40 | Radiologist sees wire on a new film; interventional radiology removes it | Earlier films were not re-read |
Causal Statements
RCA2 sets rules for how causes are written: each statement should show how a condition produced an outcome that led to the event, should avoid negative descriptors such as carelessness and should name what preceded any human error (National Patient Safety Foundation, 2015). The team agreed on five. First, because the insertion kit contains no step or place that requires the wire to be shown back on the tray, a wire can be left in without anyone noticing, which increased the likelihood of retention. Second, because the only assisting nurse had to leave the field to start a vasopressor, no second person was watching the procedure at its riskiest point. Third, because the overnight model places a single resident with no in-unit supervisor for procedures on unstable patients, the resident performed a complex insertion alone while managing a deteriorating patient. Fourth, because the radiology template for line films asks only about tip position, the reader did not report a visible wire. Fifth, because the unit was short one nurse that night, the charge nurse could not step in when the bedside nurse left.
What the Literature Adds
The event followed a known pattern. In a report of four retained guidewires after central line placement by anesthesia providers, a worsening patient condition during insertion and complex procedures needing more than one guidewire insertion were recurring features, and the institution's rate over six years was about one loss in every 3,291 procedures (Vannucci et al., 2013). Rare events of this kind are easy to dismiss as individual lapses. The pattern suggests they arise predictably when attention is pulled away at a particular moment, which is what happened at Sable Creek.
The Action Plan
RCA2 ranks actions by strength: physical changes, forcing functions and standardization are stronger than checklists and added staff, which in turn are stronger than new policies, warnings and training (National Patient Safety Foundation, 2015). The team deliberately led with stronger actions.
| Action | Strength | Owner | Measure |
|---|---|---|---|
| Standard kit with a labeled wire-return slot; the securement device is sealed in a pouch marked to be opened only after the wire is back in the slot | Stronger (standardization, partial forcing function) | Supply chain with critical care nursing | Kit in all units within 60 days |
| Nurse or second clinician must say aloud 'wire out, wire in tray' before the dressing, with authority to stop the procedure | Intermediate (checklist, redundancy) | Critical care nursing director | Observed in 90% of audited insertions |
| Unstable patients: a second nurse or rapid response nurse joins every central line insertion | Intermediate (staffing) | Chief nursing officer | Second person documented in 95% of cases |
| Senior resident or intensivist present or on video for insertions in shock at night | Intermediate (supervision) | Critical care division chief | Compliance audited monthly |
| Radiology line-film template requires a statement on any retained wire or foreign body | Intermediate (software change) | Radiology chair | Template live in 30 days |
| Simulation training on wire management during deterioration | Weaker (training) | Graduate medical education | All ICU residents trained each year |
Why the Weaker Actions Stay
Training alone would not prevent a recurrence, since the resident knew the wire had to come out. It stays in the plan because it supports the stronger actions: residents who have practiced calling out the wire during a simulated crash are more likely to do it during a real one. The team rejected a proposal to discipline the resident, noting that the causal statements showed conditions that would have challenged any clinician.
Disclosure and Support
The attending physician and the patient safety officer met the patient and her husband after the wire was removed, explained what had happened, apologized and described what the hospital would change. They offered to share the action plan when it was complete, and the couple asked to receive it. The resident and the nurse were offered peer support through the hospital's clinician support program; both said later that being interviewed as sources of knowledge rather than suspects made it easier to speak openly.
Limits of Root Cause Analysis
Root cause analysis has critics, and leaders should know why. Its effectiveness at preventing recurrences has not been well demonstrated, and analyses often consume many hours while producing weak recommendations (Wu et al., 2008). Peerally et al. (2017) described further problems: investigations of uneven quality, a tendency to settle on familiar fixes such as retraining, confusion about whether the process is meant to assign blame, and hazards that no single organization can solve alone, such as kit design. Sable Creek's plan responds by favoring stronger actions, measuring whether each one is implemented and sharing the kit redesign with its supplier and regional safety network.
Measuring Results
The patient safety committee will receive monthly reports on each action's measure for a year. Beyond implementation, the team will track retained guidewires and near misses, meaning wires found before the dressing because of the new call-out, across all central line insertions, and will re-audit a sample of radiology line reports. A near miss reported under the new process will be treated as evidence that the system is working.
Conclusion
The wire was left behind because the system allowed it: a kit with no return step, a single assistant pulled away at the riskiest moment, an unsupervised night-time procedure, a report template that did not ask, and a short-staffed unit. An analysis focused on those conditions produced actions that make the same failure harder to repeat, from a redesigned kit to a spoken check and a second person at the bedside. Measuring those actions, and learning from the next near miss, will show whether the analysis did its job.
References
National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm
Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417-422. https://doi.org/10.1136/bmjqs-2016-005511
Vannucci, A., Jeffcoat, A., Ifune, C., Salinas, C., Duncan, J. R., & Wall, M. (2013). Retained guidewires after intraoperative placement of central venous catheters. Anesthesia & Analgesia, 117(1), 102-108. https://doi.org/10.1213/ANE.0b013e3182599179
Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685-687. https://doi.org/10.1001/jama.299.6.685
Reading the EDN 812 Module 6 assignment instructions
Aspen's catalog expects EDN 812 students to establish processes for root cause analysis of sentinel events, and since the Module 6 instructions are provided in the classroom, this example carries out a complete analysis. These assignments usually ask you to describe the event, explain why it qualifies for analysis, reconstruct what happened, identify causes and propose actions with owners and measures. Follow a recognized method and say which one. Write causes as statements about conditions and processes, not as judgments about people. Rank your actions by how strongly they change the system, and include at least one action that makes the error physically harder to repeat. Address disclosure to the patient and support for the staff involved. Doctoral readers will also expect you to acknowledge the known weaknesses of root cause analysis and explain how your plan avoids them.
How this EDN 812 Module 6 example is built
The report opens with the event: a second-year resident placing a jugular line at 2:15 a.m., a falling blood pressure, a second wire pass, a nurse called away to start a vasopressor and a wire found three days later. It explains the sentinel event definition and the 45-business-day expectation, then describes an RCA2 team that interviewed staff and simulated the insertion. A three-column timeline table follows, then five causal statements covering the kit, the lone assistant, overnight supervision, the radiology template and staffing. A case report of four retained wires shows the pattern is known. A four-column action table ranks six changes from a redesigned kit to simulation training. Later sections explain why training stays, describe disclosure and peer support, weigh critiques of root cause analysis and set monthly measures including near misses.
Where the marks sit in the EDN 812 Module 6 rubric
Instructors judge a root cause analysis by how thorough the investigation was, by causal reasoning that reaches system causes, the strength of the actions and a plan to measure results. This report earns the causal reasoning marks by following RCA2's rules for causal statements and tracing each human error back to the condition that produced it. Four APA sources support it: the RCA2 guidance, a BMJ Quality and Safety critique of root cause analysis, a JAMA commentary on its effectiveness and an Anesthesia and Analgesia report on retained guidewires. The action table labels the strength of every action and gives each an owner and a measure, which graders look for first. Declining to discipline the resident, with reasons drawn from the analysis, shows the just approach to accountability that the course and the safety literature both endorse.
Common EDN 812 Module 6 mistakes, and how to avoid them
Students often write root cause analyses that end with whoever made the error, or that finish with retraining and a reminder memo. Graders read both as signs the analysis did not go deep enough. Ask why the error was possible, then why that condition existed, until you reach something a leader can change. Write each cause as a statement linking a condition to the event. Put at least one stronger action in your plan, such as a design change or forcing function, and label the strength of every action. Include how you will tell the patient and support the staff. If your event comes from your workplace, remove identifying details and follow your organization's rules on sharing safety reviews. A tutor can help you test your causal statements against the RCA2 rules before you submit.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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EDN 812 Module 6 questions, answered
What does EDN 812 Module 6 usually ask for?
Aspen's EDN 812 asks leaders to establish processes for root cause analysis of sentinel events, so a root cause analysis and action plan for one event is a typical sixth assignment. Follow your classroom prompt.
Is a retained guidewire a sentinel event if the patient is not harmed?
Yes. The Joint Commission treats unintended retention of a foreign object after an invasive procedure as a sentinel event whether or not harm results.
What makes a root cause analysis action strong?
Actions that change the physical system or force the right step, such as a redesigned kit, are stronger than checklists or staffing changes, and those are stronger than training or new policy.
Where can I find a free EDN 812 Module 6 sample paper?
The analysis is posted in full above, covering a retained central line guidewire with a timeline table, five causal statements and an action table ranked from stronger to weaker actions.
How long does a hospital have to complete a root cause analysis for a sentinel event?
The Joint Commission gives the organization 45 business days, counted from when it becomes aware of the event, to complete a comprehensive systematic analysis and its corrective action plan.