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.