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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A. 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:

1. Describe the sentinel event.

2. Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event.

3. Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event.

a. Propose ways to improve interactions among the personnel present.

4. Discuss a quality improvement tool to be used to conduct the root cause analysis.

B. Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following:

1. Recommend a risk management program or process change to ensure that the sentinel event does not recur.

a. Discuss resources available to support these changes.

C. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

D. Demonstrate professional communication in the content and presentation of your submission.