| Course | HC 405 Healthcare Quality |
|---|---|
| Unit | Unit 6 |
| Paper type | Fishbone diagram analysis |
| Length | About 760 words, 5 pages |
| Format | APA 7 student paper |
| School | Herzing University |
| Program | BS in Healthcare Administration |
| Updated | October 2026 |
Free sample paper for HC 405 Unit 6
Thirty-Five Needle Problems on the Second Shift: A Fishbone Analysis of Vascular Access Events at Gulfview Kidney Center, Each Branch Taken Two Levels Down
Student Name
Health Care Administration, Herzing University
HC 405: Healthcare Quality
Instructor Name
February 19, 2026
Thirty-Five Needle Problems on the Second Shift: A Fishbone Analysis of Vascular Access Events at Gulfview Kidney Center, Each Branch Taken Two Levels Down
The Problem at the Head
Access events that reached patients (a needle pushed through the vessel wall, a needle pulled out during treatment, or bleeding that would not stop once needles came out) occurred 35 times on the second shift at Gulfview Kidney Center in 2025, compared with 13 on the first shift and 10 on the third, with 31 of all 58 events clustered in the first or last 20 minutes of a patient's session. The problem is stated narrowly on purpose. It is not "access problems" or "staffing"; it is a particular kind of event, on a particular shift, at particular moments.
Where the Causes Came From
Three sources fed the diagram. Observation: the clinical manager and I watched eight second-shift changeovers in January, from the first patient coming off the machine to the last new patient going on, recording who did what and when. Interviews: six patient care technicians, three nurses and two patients who had experienced infiltrations, each asked what makes cannulation harder at that time of day. Existing counts: the 2025 event reports, the start-time audit and the staffing schedule. Each cause below is marked with its source, so the team can see which rest on observation or data and which are staff hypotheses still to be checked.
The Diagram, Branch by Branch
The diagram has six branches feeding the problem at the head. Each is described with its first-level cause and the deeper causes beneath it.
| Branch | First-level cause | Deeper causes | Source |
|---|---|---|---|
| People | Less experienced technicians cannulate at the second changeover | Two of the three newest technicians are scheduled on the second shift; senior technicians leave at the end of the first shift | Staffing schedule; observation |
| People | Technicians cannulate while also disconnecting other patients | Each technician is responsible for four patients whose changes overlap | Observation |
| Process | Cannulation is rushed to recover lost time | First shift runs late, so the second shift starts behind; staff try to catch up at connection | Start-time audit; interviews |
| Process | No check of needle position and taping after connection | Securing and taping practice varies by technician; no second look before the technician moves on | Observation; interviews |
| Equipment | Access assessment without ultrasound | The center's one portable ultrasound is kept in the manager's office and is rarely used for difficult accesses | Observation |
| Supplies | Needle sizes and tape not at every station | Stations are restocked at the start of the day, not between shifts, so staff substitute what is at hand | Observation |
| Environment | Crowding and noise at changeover | Patients leaving and arriving at once, family members in the aisles, alarms from several machines | Observation; patient interviews |
| Environment | Patients arriving cold | The room is kept cold for machine and staff comfort; cold arms make veins harder to feel | Patient interviews; comment cards |
| Information | Access history not visible at the chair | Notes about difficult or new fistulas are in the chart, not on the station, so the technician may not know an access is fragile | Interviews; chart review |
| Information | No handoff about difficult accesses between shifts | First-shift staff know which patients had problems but do not pass this on | Interviews |
Which Causes the Evidence Supports Most
Not every cause on the diagram is equally supported. Three rest on both observation and counts and are the strongest candidates. First, rushed cannulation when the shift starts late: the start-time audit shows second-shift starts running behind on most days, and more than half of all events fell in the minutes around connection or disconnection. Second, overlapping responsibilities at changeover: in all eight observed changeovers, at least one technician was connecting one patient while another patient assigned to the same technician was ready to come off. Third, missing information about fragile accesses: in 11 of the 35 second-shift events, the chart already noted the access as new or difficult, but nothing at the station said so.
Other causes, such as the cold room and supply gaps, are plausible and cheap to address but rest mainly on interviews. Staff experience is real but is partly a symptom of scheduling decisions rather than a cause to be fixed by telling technicians to be careful. Published work on dialysis incidents also found that errors cluster around the start and end of treatment and involve staff, communication and task factors together, which fits this diagram (Gu et al., 2014).
Choosing What to Test
The team will test two changes first, both aimed at well-supported causes and both small enough to try on one shift. First, a colored tag at the station for any access flagged as new or difficult, placed by the first-shift technician and read by the second, closing the information gap. Second, staggering second-shift connections by assigning start times in pairs rather than all at once, so that no technician connects and disconnects at the same moment. National vascular access guidance emphasizes careful assessment and cannulation of new and difficult accesses (Lok et al., 2020), which both changes support. The diagram itself follows the cause-and-effect method developed for quality control, which groups causes by category so that none is overlooked (Ishikawa, 1986).
Causes Considered and Set Aside
Two causes that staff raised were examined and set aside for now, and the reasons are recorded so that they can be revisited. Several technicians suggested that the needles the center switched to in 2024 are harder to place. The event reports do not support this as a main cause: infiltration rates on the first and third shifts, which use the same needles, did not rise. Some staff also suggested that second-shift patients have more difficult accesses. A review of the 35 events found a mix of access types and ages similar to those on the other shifts, so patient mix does not explain the difference either.
Setting these aside does not mean they are wrong. It means the evidence points more strongly elsewhere, and the first tests should go where the evidence is strongest. If the two tested changes do not reduce second-shift events, the needle question will be the next to test, using a short trial on one shift with the previous needle.
References
Gu, X., Itoh, K., & Suzuki, S. (2014). An error taxonomy system for analysis of haemodialysis incidents. Journal of Renal Care, 40(4), 239-248. https://doi.org/10.1111/jorc.12081
Ishikawa, K. (1986). Guide to quality control (2nd rev. ed.). Asian Productivity Organization.
Lok, C. E., Huber, T. S., Lee, T., Shenoy, S., Yevzlin, A. S., Abreo, K., Allon, M., Asif, A., Astor, B. C., Glickman, M. H., Graham, J., Moist, L. M., Rajan, D. K., Roberts, C., Vachharajani, T. J., & Valentini, R. P. (2020). KDOQI clinical practice guideline for vascular access: 2019 update. American Journal of Kidney Diseases, 75(4, Suppl. 2), S1-S164. https://doi.org/10.1053/j.ajkd.2019.12.001
HC 405 Unit 6 instructions, in plain terms
Unit 6 asks you to complete a fishbone diagram analysis for a quality problem. Expect to state the problem precisely, describe where causes came from, present each branch with causes at least two levels deep, weigh the evidence for each cause, choose what to test and record causes set aside. Students often ask how deep to go. Ask why at least twice on each branch, so causes reach something that can be changed. Gather causes from more than one source, such as observation, interviews and data. Not every cause is equally supported, so rank them. Choose small tests aimed at well-supported causes. Record ideas set aside with reasons, so they can be revisited later.
How the HC 405 Unit 6 example is put together
The analysis opens with a precise problem statement and the count of 35 events. The sources section describes January observations, interviews with technicians and nurses and report data by shift. The diagram section walks branch by branch: people, with new technicians on fragile accesses; process, with all four patients starting at once; equipment; supplies; environment, with crowded changeovers; and information, with access notes missing at the station. The evidence section ranks three causes supported by both observation and counts. The testing section chooses the tag and staggered starts, both small enough for one shift. The set-aside section explains why a needle brand change and staffing ratios were not pursued yet.
Reading the HC 405 Unit 6 rubric
Herzing's rubric for a fishbone analysis typically covers the problem statement, sources, the diagram, depth of causes, ranking by evidence, choice of tests and causes set aside. Ranking causes by evidence matters most, because a diagram full of plausible causes is only useful once the team knows which ones the data support. Problem points reward a precise, counted statement. Source criteria look for more than one method. Diagram credit goes to six branches with causes two levels deep. Test points reward small changes aimed at strong causes. Set-aside causes should have reasons. Ishikawa's guide to quality control, Gu's dialysis error taxonomy and the KDOQI vascular access guideline support the analysis.
HC 405 Unit 6 help: mistakes that cost points
Fishbone analyses in HC 405 Unit 6 run into trouble when causes stop at the first level, such as staff error. Another frequent problem is a vague problem statement. Students often rely on brainstorming alone without observation or data. Every cause is treated as equally likely. Tests are too large to try on one shift. Causes set aside are not recorded. Branches are left empty. The diagram is not linked to the next step. Blame creeps in, which makes staff less willing to report the next event and starves the analysis of the very information it needs. Finally, rank causes by what the evidence shows, because graders reward an analysis that leads straight to a small, well-aimed test.
Get a HC 405 Unit 6 example written to your instructions
Send the Unit 6 instructions and the rubric from your HC 405 classroom, plus the problem your section assigned or the failure you want examined. We write a custom example with the head stated narrowly, branches driven past the obvious, causes sourced and one branch argued above the rest, back in 24 to 48 hours. The first custom sample is free.
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HC 405 Unit 6 questions, answered
Which categories should the branches use?
The traditional six work for almost any clinical problem: people, process, equipment, supplies, environment and information. Some sections prefer a shorter set, so check first. What matters more than the labels is that every category actually gets populated, since a branch left with one thin cause usually means the writer stopped thinking rather than that the category was irrelevant.
Does the diagram have to be drawn by hand?
Any legible form is fine unless your instructions say otherwise, and a clear drawing photographed straight is perfectly acceptable. What gets marked down is a diagram nobody can read: labels too small, branches unlabeled, or so many twigs that the structure disappears. Keep the categories visible, keep the text short on the diagram itself, and let the prose carry the detail.
How do I choose which branch to pursue?
Weigh two things: how much of the problem the cause plausibly explains, and whether anything could be done about it inside your setting. A cause that explains most of the problem but sits with a national supplier is a poor choice for a small test. Say which pair of considerations you used, because the reasoning behind the selection is what gets read.
Where can I find a free HC 405 Unit 6 sample paper?
Read the complete HC 405 Unit 6 fishbone diagram analysis here at no charge, second-shift needle problems at a dialysis center with six branches and ranked causes. Ask for a custom analysis of another problem.
How do you do a fishbone diagram for a quality problem?
State the problem precisely, draw branches such as people, process, equipment, supplies, environment and information, ask why at least twice on each, then rank causes by evidence. This sample does that.