Page 93 - Clinical Managers Orientation Binder

6/28/2019

TECHNIQUE USED FOR INVESTIGATING
SERIOUS EVENTS

• Root Cause Analysis (RCA) Used for

• Adverse events
• Sentinel events
• Near misses

• Identify the conditions that existed, which contributed to
the event
• Data collection

• Review of information
• Interviews all parties involved

• Recommendations and correct action plan (CAP)
for improvement and prevention
6/28/2019 3:57 PM Date Last Edited: 13

ROOT CAUSE ANALYSIS (RCA)

• Focus of the Technique
• Involve team for solutions
• Focus is on system gaps, not people
• Process for improvement
• Prevention of future occurrences
• Not punitive

Quality Manager works with the branch to discuss review finding and
develop and implement corrective action plan and steps to prevent further
occurrences

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