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Root Cause Analysis: Responding to a Sentinel Event

doi: 10.1097/NHH.0b013e3182a826b9
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Root Cause Analysis: Responding to a Sentinel Event


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To describe the use of root cause analysis, an evidence-based structure for methodical investigation and comprehensive review of a sentinel event enabling appropriate identification of opportunities for improvement.


After reading this article and taking this test, you should be able to:

  1. Identify the keys concepts, principles, and regulations related to the investigation of sentinel events.
  2. Recognize the essential and recommended features of root cause analysis.
  1. The Joint Commission defines a sentinel event as an occurrence involving risk of or actual death or serious physical or psychological injury that is
    1. preventable.
    2. negligent.
    3. blameless.
    4. unexpected.
  2. In July 2013, the Joint Commission expanded its list to include certain events to staff, visitors, or vendors that
    1. have no permanent consequences.
    2. carry the potential for damaging litigation.
    3. occur on the health care organization's premises.
    4. do not involve actions by the health care organization's staff.
  3. The Joint Commission labels certain types of events as sentinel because they
    1. involve a population especially susceptible to injury.
    2. require an immediate investigation and response.
    3. mandate the initiation of surveillance and gatekeeping.
    4. require a subsequent watchful approach for recurrences.
  4. Root cause analysis (RCA) is used to improve systems, diminish harm, and prevent recurrence of adverse events
    1. without directing individual blame.
    2. with decision-making authority involved.
    3. by pinpointing cases of human error.
    4. by accepting variations in performance.
  5. The goals of RCA are met through in-depth examination of an organization's processes and systems with the purpose of answering three questions, one of which is
    1. what are the risks for harm in allowing possible causes of the event to continue?
    2. are there specific individuals involved with a history of this type of event?
    3. what can be done to prevent the event from happening again?
    4. would the event have occurred without the suspected cause?
  6. When does preparation for root cause analysis begin?
    1. Immediately after identification of the event as sentinel
    2. Within 24 to 478 hours of the particular event
    3. As soon as an investigative team can be convened
    4. When the assessment of the injured individual(s) is completed
  7. The Joint Commission allows what period of time for completion of the analysis and development of an action plan?
    1. 15 days
    2. 30 days
    3. 45 days
    4. 60 days
  8. The first step in the RCA process is
    1. gathering relevant data.
    2. soliciting administrative support.
    3. proposing problem-solving strategies.
    4. identifying team members.
  9. Fishbone diagrams
    1. highlight contributing factors and causes.
    2. illustrate a comparison between process successes and failures.
    3. provide a framework and action plan template.
    4. outline processes as designed and carried out.
  10. Teams are most effective when members are chosen for their willingness to
    1. function independently and in groups.
    2. participate and cooperate.
    3. engage with organizational leadership.
    4. investigate causes and effects.
  11. System failures that produce consequences are called
    1. causal disparities.
    2. etiological input.
    3. contributing factors.
    4. contingent variations.
  12. According to the Veterans Health Administration, failure to act is only a root cause when
    1. violations have a preceding cause.
    2. it demonstrates cause and effect.
    3. the identified cause is actionable.
    4. there is a preexisting duty to act.
  13. Which of the following questions is the key to the discovery of contributing factors?
    1. What if?
    2. Why?
    3. How?
    4. Why not?
  14. The most effective strategies for preventing reoccurrence of sentinel events are those that are directed at
    1. individual performance or behavior.
    2. identification and reporting protocols.
    3. system and process issues.
    4. prompt assessment and treatment of injuries.
  15. Of the actions listed by the Department of Veterans Affairs National Center for Patient Safety in its Hierarchy of Actions, which of these is an example of a weaker action?
    1. Double checks
    2. Standardization
    3. Redundancy
    4. Software modifications


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