The Joint Commission requires a root cause analysis for allsentinel

Introduction:The Joint Commission requires a root cause analysis for allsentinel events. These analyses can be of enormous value. Theycapture both the big-picture perspective and the details. Theyfacilitate system evaluation analysis of need for correctiveaction and tracking and trending. Managers will be able todetermine how often a particular error occurs or how often aparticular floor or unit of the hospital is involved. Thisinformation may provide clues to the problem. A root cause analysisis very useful and important especially in near-miss scenarios. Thetechnique is applicable not only to laboratory medicine but also toother healthcare-associated disciplines.Task:A. Conduct a root cause analysis of the sentinelevent found in the attached Accreditation Audit Case Study bydoing the following:

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