Identify and summarise the key problems leading to Elizabeth’s admission into intensive care using the 5W’s and 1H approach


Learning outcomes

To successfully complete this assessment, you will:

  • Understand the impact of a preventable event to the patient, their family, and the healthcare organisation
  • Critically analyse and identify different causes and effects of preventable problems, including recognising and responding to a deteriorating patient in a timely and appropriate manner
  • Provide evidence-based recommendations for future nursing practice to prevent seminal patient events.


Assessment description

In this subject we have explored several aspects of Elizabeth, a patient admitted with acute chronic respiratory failure (see Elizabeth case study). In this case study, we have examined various stages of her admission, including looking at key features of both her respiratory and cardiac failure that resulted in a subsequent admission to intensive care for invasive ventilation. Elizabeth’s admission to intensive care was potentially preventable. Nurses and other members of the interdisciplinary team share a responsibility in reflecting and evaluating significant events by analysing the events that took place and make recommendations for future practice to improve and ensure high-quality patient care.


In this assessment task, you are required to undertake a root cause analysis (RCA) to identify the problem(s) and possible root causes. As part of your RCA, you are required to provide strategies and recommendations for future clinical practice. Refer to the information provided under ‘Resources for root cause analysis’ and review the resources you need to complete this assessment.


Assessment task

Provide a root cause analysis of Elizabeth’s case study, examining key events that lead to her admission to intensive care. In your root cause analysis, you are required to:

  1. Identify and summarise the key problems leading to Elizabeth’s admission into intensive care using the 5W’s and 1H approach (what, when, where, who, why, and how).
  2. Consider the impact of Elizabeth’s admission to herself, her family, and the healthcare organisation.
  3. Identify possible causes using a cause and effect-style fishbone analysis model and identify preventable problems.
  4. Provide a summary of your analysis and an explanation of your findings.
  5. Based on your cause and effect analysis, provide evidence-based recommendations for future nursing practice.



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