The Joint Commission requires a root cause analysis for all sentinel events. These analyses can be of enormous value. They capture both the big-picture perspective and the details. They facilitate system evaluation, analysis of need for corrective action, and tracking and trending. Managers will be able to determine how often a particular error occurs or how often a particular floor or unit of the hospital is involved. This information may provide clues to the problem. A root cause analysis is very useful and important especially in near-miss scenarios. The technique is applicable not only to laboratory medicine but also to other healthcare-associated disciplines.
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- Provide a summary of the following aspects of a root cause analysis related to the sentinel event found in the attached Accreditation Audit Case Study – Task 2 Specific artifacts by doing the following:
- Describe the sentinel event.
- Explain the roles (i.e. responsibilities, etc.) of each of the personnel present during the sentinel event.
- Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event.
- Propose ways to improve interactions among the personnel present.
- Discuss a quality improvement tool to be used to conduct the root cause analysis.
- Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following:
- Recommend a risk management program or process change to ensure that the sentinel event does not recur.
- Discuss resources available to support these changes.
- Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
- Demonstrate professional communication in the content and presentation of your submission.