PT - JOURNAL ARTICLE AU - Dhingra, Jitesh AU - Farrell, Mary Beth AU - Halkar, Raghuveer TI - Root Cause Analysis in Nuclear Medicine for Sentinel Events AID - 10.2967/jnmt.122.264851 DP - 2022 Dec 01 TA - Journal of Nuclear Medicine Technology PG - 301--308 VI - 50 IP - 4 4099 - http://tech.snmjournals.org/content/50/4/301.short 4100 - http://tech.snmjournals.org/content/50/4/301.full SO - J. Nucl. Med. Technol.2022 Dec 01; 50 AB - 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.