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According to The Joint Commission, a root cause is “a finding related to a process or system that has a potential for redesign to reduce risk.”

Root cause analysis (RCA) refers to the process of evaluating the circumstances surrounding a sentinel event or “near miss” event. These analyses allow facilities to see the big picture as well as the details related to an event. The RCA allows facilities to evaluate systems, analyze the need for corrective action and facilitate tracking and trending. The RCA must involve all parties who were involved in the error in order to obtain all the important details to conduct a thorough analysis. 

This month’s civil topic is Serious Reportable Events (“never events”). Topics covered are:

  • “Never event” defined (6/2/14)
  • Reporting Requirements (6/9/14)
  • Finding the root of the problem (6/16/14)
  • Legal implications (6/23/14)

Note: To see all posts in this topic, click here.



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