RT Journal Article
SR Electronic
T1 Root Cause Analysis in Nuclear Medicine for Sentinel Events
JF Journal of Nuclear Medicine Technology
JO J. Nucl. Med. Technol.
FD Society of Nuclear Medicine
SP 301
OP 308
DO 10.2967/jnmt.122.264851
VO 50
IS 4
A1 Jitesh Dhingra
A1 Mary Beth Farrell
A1 Raghuveer Halkar
YR 2022
UL http://tech.snmjournals.org/content/50/4/301.abstract
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.