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Patient Safety Monitor (Briefings on Patient Safety) (Single Issue)
May 2000
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Building a team is key to a ‘thorough and credible’ root-cause analysis
Editor’s note: This is the first article in a three-part series on how to avoid the pitfalls when performing a root-cause analysis (RCA) as required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) under its sentinel event policy. This month, BOPS gives pointers on how to build your RCA team.
A tragedy has occurred at your hospital. A patient has unexpectedly died and there’s strong circumstantial evidence that the cause of death is related to a preventable medication error
