TY - JOUR T1 - Root Cause Analysis in Nuclear Medicine for Sentinel Events JF - Journal of Nuclear Medicine Technology JO - J. Nucl. Med. Technol. SP - 301 LP - 308 DO - 10.2967/jnmt.122.264851 VL - 50 IS - 4 AU - Jitesh Dhingra AU - Mary Beth Farrell AU - Raghuveer Halkar Y1 - 2022/12/01 UR - http://tech.snmjournals.org/content/50/4/301.abstract N2 - A sentinel event is any unexpected event that results in death or serious physical or psychologic injury to a patient unrelated to a patient’s illness. Establishing and determining cause-and-effect relationships are key to preventing future sentinel or 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, 9-step, RCA approach for investigating sentinel events and illustrates the technique with a nuclear medicine example. ER -