The death of a patient (as described in the Real Life Scenario (text Chapter 11, pages 233-234) is always classified as a sentinel event. The Joint Commission requires the organization to do a root-cause analysis when such an event occurs. The purpose of the analysis is to discover what processes led to the occurrence. In this assignment, students will use the “cause and effect fishbone diagram” which is the most commonly used technique used in a root cause analysis. This exercise will give students experience in conducting the root cause analysis that is used in actual hospital situations.
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