PT  - JOURNAL ARTICLE
AU  - Jitesh Dhingra
AU  - Mary Beth Farrell
AU  - Raghuveer K. Halkar
TI  - Root Cause Analysis in Nuclear Medicine for Sentinel Events
AID  - 10.2967/jnmt.122.264851
DP  - 2022 Oct 01
TA  - Journal of Nuclear Medicine Technology
PG  - jnmt.122.264851
4099  - http://tech.snmjournals.org/content/early/2022/10/04/jnmt.122.264851.short
4100  - http://tech.snmjournals.org/content/early/2022/10/04/jnmt.122.264851.full
AB  - 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.