Fishbone Diagram Healthcare Example: A Nursing QI Guide

Fishbone diagram healthcare example searches usually come from nursing students and improvement teams who know a problem exists but are unsure how to identify the conditions producing it. A fishbone diagram, also called an Ishikawa or cause-and-effect diagram, helps a team organise possible causes around one clearly defined outcome before deciding what to change.

In nursing quality improvement (QI), the tool can be used for problems such as inpatient falls, delayed medicines, incomplete observations, pressure injuries, discharge delays, specimen errors and unreliable handovers. The Institute for Healthcare Improvement (IHI) describes the cause-and-effect diagram as a graphical method for exploring and displaying the possible causes of an effect, while NHS England includes cause-and-effect diagrams among practical tools used within quality management and improvement systems (Institute for Healthcare Improvement [IHI], 2017; NHS England, n.d.).

The diagram is most valuable when it leads to investigation. It should not be presented as proof that every item written on a branch caused the problem. The strongest nursing QI projects use the fishbone to generate hypotheses, verify the most plausible causes with local evidence, convert those findings into change ideas, test them through PDSA cycles and then examine data over time.

What is a fishbone diagram in nursing quality improvement?

A fishbone diagram places the problem, outcome or “effect” at the head of the diagram. The main branches represent broad groups of possible causes, while smaller branches hold more specific causes. The shape resembles a fish skeleton, which explains the common name. The same tool is also known as an Ishikawa diagram after Kaoru Ishikawa, who popularised cause-and-effect analysis in quality management.

IHI explains that a cause-and-effect diagram can help teams recognise that many causes may contribute to one effect, display relationships between those causes and identify areas where improvement work may be useful (IHI, n.d.-a). In a nursing context, this is important because care outcomes rarely arise from one isolated action. Staffing, clinical complexity, handover, workflow, equipment, electronic systems, environment and patient needs may interact.

For this reason, a fishbone should move the project away from statements such as “staff need to be more careful”. Instead, it helps the team ask which parts of the system make the desired action more or less reliable.

When a fishbone diagram healthcare example is useful

A fishbone is appropriate when the project has identified a recurring problem but the reasons are unclear, disputed or likely to be multifactorial. AHRQ includes fishbone diagramming and the 5 Whys among root-cause approaches that can help healthcare teams understand underlying factors affecting performance (Agency for Healthcare Research and Quality [AHRQ], 2025).

Nursing projects that can benefit include:

• falls remaining above the ward target;
• time-critical medicines being administered late;
• pain reassessment not occurring within the intended interval;
• pressure-injury prevention bundles being completed inconsistently;
• clinical deterioration not being escalated reliably;
• patient discharge being delayed after medical readiness;
• specimen labelling or transport errors;
• important information being missed during handover;
• catheter care or infection-prevention processes varying between staff; and
• patient education being delivered inconsistently.

A fishbone is less useful when the real problem has not yet been defined. If a team simply says “communication is poor”, it may be better to first identify which communication process is failing, for whom, where and with what measurable consequence.

How to plan a fishbone diagram healthcare project

1. Write a neutral and measurable problem statement

The problem should describe the observed effect rather than blame a person or assume the cause. For example, “inpatient falls remain above the ward improvement target” is stronger than “nurses are failing to prevent falls”. The first statement permits investigation. The second embeds an untested explanation.

Where data are available, define the baseline clearly: patient group, unit or pathway, time period, measure and size of the problem. This information later supports the project aim and enables the team to judge whether change has produced improvement.

2. Bring together people who understand the work

The team should include people who experience different parts of the process. In a falls project this might include registered nurses, healthcare support workers, physiotherapists, pharmacists, ward managers and patient or carer representatives. AHRQ recommends involving people with appropriate knowledge of the problem before identifying categories and possible causes (AHRQ, n.d.).

Frontline involvement helps reveal the difference between the written process and what actually happens during busy clinical work. A policy may state that reassessment occurs after clinical change, but staff may identify practical barriers such as unclear triggers, duplication, poorly placed equipment or competing urgent tasks.

3. Choose categories that fit nursing care

Classic fishbone categories include people, methods, equipment, materials and environment. Healthcare teams can adapt them. A useful nursing structure is shown below.

Category	Questions to ask	Example nursing cause
People	Do staffing, knowledge, role clarity, supervision or workload affect reliability?	Responsibility for reassessment is unclear after transfer.
Process	Does the pathway contain unclear triggers, duplication, delay or missing steps?	Falls risk is assessed on admission but not reliably after deterioration.
Equipment/technology	Are devices, supplies and electronic systems available and easy to use?	Walking aids or call bells are not consistently within reach.
Environment	Do lighting, layout, interruptions, noise or storage create risk?	Night-time routes to the toilet may be poorly lit or obstructed.
Communication/team	Is important information transferred at the correct time and to the correct person?	Mobility status is inconsistently included in handover.
Patient factors	Do acuity, cognition, medication, mobility or communication affect the process?	Acute confusion increases unsupervised mobilisation.

The categories are prompts, not rules. A medication-safety project may need separate branches for prescribing, pharmacy, administration and electronic systems. A community nursing project might use access, inter-agency working, travel, home environment and family support.

Worked fishbone diagram healthcare example: inpatient falls

Imagine a medical ward where the monthly falls rate has remained above the local target despite routine falls training. The improvement team decides not to assume that more education is the answer. It creates a fishbone diagram to explore why the falls-prevention process may be unreliable.

The figure deliberately uses cautious language. “Mobility status omitted from handover” or “risk assessment not repeated after change” should initially be treated as hypotheses. The team then checks whether these events actually occur, how often they occur and whether they are plausibly connected to falls or near misses.

This is where the fishbone becomes analytical rather than decorative. An assignment that simply inserts a diagram and immediately calls the branches “root causes” has skipped the verification stage.

How to identify causes without turning the diagram into guesswork

During the brainstorming stage, ask what could contribute to the problem and place the ideas on the branches. Avoid judging every idea immediately because premature filtering can cause the team to miss less obvious system factors. However, once the broad list is developed, the project should move from divergence to evidence-based prioritisation.

For each proposed cause, ask:

• What evidence supports this?
• How often does it happen?
• Does it occur before or around the outcome?
• Could another factor explain the same observation?
• Can the team influence or modify it?
• Would changing it plausibly improve the target outcome?

Possible evidence includes observation, audit data, electronic timestamps, incident reports, patient feedback, staff feedback, care records and process measures. If the project is an academic scenario and no local dataset is supplied, do not invent figures. State what data would be collected to confirm or reject the proposed causes.

Use process mapping before the fishbone when the pathway is unclear

A process map or flowchart shows what happens, in what order and where responsibility or information moves. IHI recommends careful examination of the existing system, including flowcharts, when selecting changes for improvement (IHI, n.d.-b). AHRQ also provides process-mapping training as part of its practice-facilitation curriculum (AHRQ, n.d.).

Suppose a discharge QI project is experiencing delays. A fishbone may generate dozens of possible causes, but a process map can first show that most delay occurs between the decision-to-discharge and pharmacy confirmation. The fishbone can then focus on that specific part of the pathway rather than analysing every aspect of discharge.

Process mapping therefore answers where does the process break down? The fishbone then helps answer why might that breakdown be occurring?

Use 5 Whys to examine an important fishbone branch

The 5 Whys technique explores one identified problem by repeatedly asking why it occurred. The number five is not mandatory. AHRQ notes that a team may need fewer or more than five questions to reach a useful explanation (AHRQ, n.d.).

For example:

1. Why was a repeat falls-risk assessment delayed? The change in mobility was not recognised as a trigger.
2. Why was the trigger not recognised? The reassessment criteria were not prominent in the workflow.
3. Why were they not prominent? They were embedded in a long electronic form rather than linked to the relevant clinical event.
4. Why did that matter? Staff had to rely on memory during competing tasks.
5. Why was reliance on memory accepted? The process had not been redesigned after the electronic documentation change.

This produces a more useful improvement target than “the nurse forgot”. However, the chain should stop when answers become speculative. Complex healthcare problems also branch, so a single 5 Whys chain should not replace the wider fishbone when several factors interact.

Use a Pareto chart to decide which causes deserve priority

When the team can count defects or contributory factors, a Pareto chart helps display which categories occur most often. It can be particularly useful after a fishbone has produced a long list of possible causes. For example, an audit of 80 delayed observations may show that most delays cluster around three recurring circumstances rather than being evenly distributed across every category.

Pareto analysis does not prove which cause has the greatest clinical importance, and frequent events are not automatically the most dangerous. Nevertheless, it helps prevent a project from spreading effort across too many low-frequency issues. IHI includes Pareto charts alongside cause-and-effect diagrams, run charts and PDSA worksheets in its Quality Improvement Essentials Toolkit (IHI, 2017).

Move from causes to a driver diagram

Once the important causes are supported by evidence, a driver diagram can convert the diagnostic work into an explicit improvement theory. The aim is placed at the left, followed by primary drivers, secondary drivers and specific change ideas. IHI describes the driver diagram as a way to organise a team’s theory about what changes are likely to produce improvement (IHI, n.d.-b).

For the inpatient-falls example, a primary driver might be reliable identification of changing mobility risk. Secondary drivers could include clear reassessment triggers, visible mobility status and reliable handover. Change ideas might include an event-triggered reassessment prompt, a standard mobility status field in handover or a bedside visual cue developed with governance approval.

This is a critical transition. The fishbone says, “these factors may be contributing”. The driver diagram says, “these are the parts of the system we believe must change to achieve the aim”.

How the related nursing QI tools fit together

Tool	Main question	Typical role in the project
Process map/flowchart	What actually happens?	Shows sequence, handoffs, duplication, delay and variation.
Fishbone diagram	Why might the problem happen?	Organises possible causes into a system view.
5 Whys	Why does this particular cause occur?	Explores one causal pathway in greater depth.
Pareto chart	Which recurring issues account for most of the observed defects?	Helps prioritise when frequency data are available.
Driver diagram	What must change to achieve the aim?	Links the project aim, drivers and change ideas.
PDSA cycle	Will this change work here?	Tests change on a small scale and supports learning.
Run/SPC chart	Is performance changing over time?	Shows time-ordered variation and whether improvement is sustained.

NHS England’s quality-management guidance similarly lists cause-and-effect diagrams, Pareto charts, flowcharts, driver diagrams, the Model for Improvement, PDSA testing and SPC charts as tools used in quality improvement systems (NHS England, n.d.).

From fishbone analysis to PDSA testing

A fishbone should not end with a generic recommendation such as “provide staff training”. Instead, choose change ideas that address verified and modifiable causes. If handover is the problem, redesigning the handover process may be more direct than repeating education. If equipment location is the problem, standardising placement may be stronger than reminding staff to search more carefully.

The Model for Improvement asks three core questions: what are we trying to accomplish, how will we know a change is an improvement, and what changes can we make that will result in improvement. Change ideas are then tested using Plan-Do-Study-Act cycles. IHI’s toolkit describes PDSA as rapid-cycle testing that helps teams learn methodically whether a change produces improvement (IHI, 2017).

For example, a ward could test a revised mobility-status handover field with one nursing team for two shifts. The team would predict what should happen, collect a simple process measure, study what worked and what failed, then adapt the idea before a wider test.

Measure whether the change actually improves nursing care

A QI project needs more than an intervention. It needs measures. A practical measurement plan usually includes:

• Outcome measure: the result the project ultimately wants to improve, such as falls per 1,000 occupied bed days.
• Process measure: whether the new process is being carried out, such as the proportion of eligible patients receiving repeat mobility-risk assessment after a defined trigger.
• Balancing measure: whether the change creates an unintended problem, such as documentation burden, delayed medicines or unnecessary alerts.

Run charts or SPC charts can then show data in time order rather than relying only on before-and-after averages. NHS England identifies SPC as part of quality control and improvement, while IHI includes run and control charts in its core improvement toolkit (NHS England, n.d.; IHI, 2017).

Common mistakes when using a fishbone diagram in a nursing project

• Starting with blame. “Poor nursing practice” is not a useful cause category.
• Using the diagram as proof. Brainstormed branches are hypotheses until supported.
• Including every possible cause. A project must eventually prioritise.
• Mixing causes and solutions. “Introduce training” is a change idea, not a cause.
• Forcing generic categories. Adapt the bones to the clinical process.
• Ignoring patients and carers. They may identify access, communication or workflow issues that records do not show.
• Stopping after the diagram. Fishbone analysis should lead to investigation, a change theory, testing and measurement.
• Inventing local data. In an academic scenario, clearly distinguish supplied evidence from data that would need to be collected.

How to write the fishbone section in a nursing QI assignment

A strong academic section should explain why the tool was chosen, how the problem was defined, who would contribute, how categories were selected and how proposed causes would be verified. The diagram should be labelled as a figure and discussed in the main text rather than inserted without explanation.

For example, rather than writing “the fishbone identified staff workload as the root cause”, write that “fishbone analysis generated workload as one plausible contributory factor; this would require verification using staffing, workload and event-timing data before being treated as a priority driver”. This language demonstrates methodological caution and avoids confusing brainstorming with causal evidence.

If the work is intended for publication, the SQUIRE 2.0 reporting framework is useful because it asks authors to describe the local problem, rationale, specific aims, context, intervention, measures, analysis and learning from the project (Ogrinc et al., 2016). The fishbone can support the rationale and diagnostic phase, but the complete report still needs the rest of the improvement story.

Ethics, governance and professional considerations

Quality improvement and formal research are not automatically the same activity. A local QI project may be undertaken as part of clinical governance, but students and staff must still follow organisational requirements for data access, confidentiality, patient involvement and project approval. Where an academic project involves patient-level data or activities beyond routine improvement, the relevant university and healthcare governance routes should be checked before work begins.

De-identify any patient or staff information used in teaching or academic writing. Do not copy identifiable incident details into an assignment. If the project is based on a supplied case, work only with the information provided and state what additional evidence would be needed rather than fabricating missing findings.

How this guide differs from root cause analysis

A fishbone diagram can be used within root-cause or contributory-factor analysis, but the two are not identical. A fishbone is one visual tool for organising possible causes. Root cause analysis is a broader investigative approach that may include chronology, interviews, records, causal testing and action planning. In current UK NHS practice, patient-safety learning also sits within the wider Patient Safety Incident Response Framework rather than assuming that every event has one single root cause.

For a broader incident-analysis method, see our nursing root cause analysis guide. For the complete project structure, see how to write a nursing quality improvement project.

Getting help with a nursing QI or capstone project

If your QI project is part of a dissertation, capstone or evidence-based practice assessment, the most useful support is often method-specific rather than generic writing. Our nursing capstone project support page explains support for problem definition, implementation planning, measures and evaluation. You can also review the wider nursing dissertation support services, see how the support process works, or use the contact page to share a brief.

Before requesting paid support, review the site’s refund policy and nursing dissertation samples and research guidance. These pages explain service boundaries and how example material should be used responsibly.

Frequently asked questions

What is the main purpose of a fishbone diagram in nursing?

Its main purpose is to organise possible causes of a defined problem so the team can investigate them systematically. It helps broaden thinking beyond one obvious explanation and makes system factors visible.

Is a fishbone diagram the same as 5 Whys?

No. A fishbone explores multiple branches of possible causes. The 5 Whys follows one problem or branch in greater depth by repeatedly asking why it occurs. They are often used together.

Should a fishbone diagram include patient factors?

It can, when patient characteristics genuinely influence the process. However, patient factors should not become a way to blame patients. The analysis should also examine whether the care system anticipates and responds reliably to those needs.

Can I use a fishbone diagram without local data?

You can use it to generate plausible causes, but you should label them as hypotheses or proposed contributory factors. In an academic assignment, explain what evidence would be required to verify them rather than inventing local findings.

What tool should be used after the fishbone?

It depends on what the team learns. A Pareto chart may help prioritise recurring causes, a driver diagram can convert verified causes into an improvement theory, PDSA cycles can test change ideas, and run or SPC charts can monitor performance over time.

Can a fishbone diagram be used in a nursing dissertation?

Yes, particularly in QI, service-improvement and capstone work. It should be justified, labelled as a figure, discussed critically and connected to evidence, change ideas and evaluation rather than included only as a visual.

Related Nursing Guides

• Risk Assessment Matrix for Nursing QI Projects: A 5×5 Guide
• A Priori vs Post Hoc Power Analysis in Nursing
• Effect Size for Nursing Research: SPSS and G*Power Guide

Conclusion

A fishbone diagram is most useful in nursing quality improvement when it is treated as the beginning of investigation rather than the end. Define one measurable problem, involve people who understand the process, organise plausible causes, verify them with evidence and prioritise those that are modifiable and important. Then use complementary tools to move from understanding the problem to designing, testing and measuring change. In this way, a fishbone diagram healthcare example becomes a practical improvement method rather than a decorative assignment figure.

References

• Agency for Healthcare Research and Quality. (2025). Using root cause analysis to improve quality and performance. AHRQ. https://www.ahrq.gov/evidencenow/tools/root-cause-analysis.html
• Agency for Healthcare Research and Quality. (n.d.). Practice facilitation training modules: Process mapping; the 5 Whys and fishbone diagramming. AHRQ. https://www.ahrq.gov/ncepcr/tools/transform-qi/deliver-facilitation/modules/index.html
• Institute for Healthcare Improvement. (2017). Quality Improvement Essentials Toolkit. IHI. https://www.ihi.org/library/tools/quality-improvement-essentials-toolkit
• Institute for Healthcare Improvement. (n.d.-a). Cause and effect diagram. IHI. https://www.ihi.org/library/tools/cause-and-effect-diagram
• Institute for Healthcare Improvement. (n.d.-b). Model for Improvement: Selecting changes. IHI. https://www.ihi.org/library/model-for-improvement/selecting-changes
• NHS England. (n.d.). Quality management systems. NHS Impact. https://www.england.nhs.uk/nhsimpact/about-nhs-impact/quality-management-systems/
• Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986–992. https://doi.org/10.1136/bmjqs-2015-004411