Root Cause Analysis in Nuclear Medicine for Sentinel Events.

Abstract

A sentinel event is any unexpected event that results in death or serious physical or psychological injury to a patient unrelated to a patient's illness. Establishing and determining cause-and-effect relationships is key to preventing future sentinel/near-miss events. However, it can be challenging to establish a cause-and-effect relationship when a process involves multiple steps or people. Root cause analysis (RCA) is a technique that can pinpoint the causes of sentinel events for medical procedures involving numerous steps and people. This article provides a rationale for RCA and the basic steps in a nonmedical RCA investigation. The article then describes a more detailed, nine-step RCA approach for investigating sentinel events and illustrates the technique with a nuclear medicine example.