Analysis of Sentinel Event

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RUNNING HEAD: ANALYSIS OF SENTINEL EVENT 1 Analysis of Sentinel Event Western Governors University ANALYSIS OF SENTINEL EVENT 2 Unexpected adverse patient outcomes, such as death or severe physical or psychological injury, seldom occur due to a single causative factor within a healthcare organization. A root cause analysis (RCA) is a technique used to assist a healthcare organization in understanding the origin of adverse patient outcomes, and help develop processes that would prevent recurrence of adverse patient events. RCA focuses on the processes within the organization that contributed to the event, not a soul causative factor. A RCA looks to answer what happened to cause the event, what can be changed within the organization to prevent recurrence of the event, and evaluates if the changes that were implemented improved patient safety within the organization (Huber & Ogrinc, 2014). The complexity of a healthcare organization makes it difficult to conduct a RCA alone. An interdisciplinary team consisting of 4 to 6 people must be formed to conduct a RCA. The team should be comprised of a member from each discipline that was involved in the event. Members from quality improvement and risk management should also be included on the team. On occasion, it is beneficial to include the patient or family member who has been effected by the event on the team. The roles of the team include a team leader, an advisor, a recorder, and team members. After the team is formed, each of its members assumes one of the four roles (Huber & Ogrinc, 2014). There are various steps to performing a RCA, The team first identifies what happened. In this step the team collects information, and seeks to understand what
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