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Western Governors University Root Cause Analysis for All Sentinel Events Paper

Western Governors University Root Cause Analysis for All Sentinel Events Paper


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.


Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

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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.

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