705.3.2: Resource Assessment – The graduate identifies and assesses external and internal
resources available to a healthcare organization.
705.3.5: Quality Improvement – The graduate designs quality improvement programs to enhance
the level of patient care in a healthcare organization.
705.3.8: Risk Management – The graduate develops risk management programs that result in
improved quality patient care.
705.3.9: Effective Interactions – The graduate can effectively interact with physicians, nurses,
and other healthcare providers.
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The Joint Commission requires a root cause analysis for all sentinel events. These analyses can
be of enormous value. They capture both the big-picture perspective and the details. They
facilitate system evaluation, analysis of need for corrective action, and tracking and trending.
Managers will be able to determine how often a particular error occurs or how often a particular
floor or unit of the hospital is involved. This information may provide clues to the problem. A root
cause analysis is very useful and important especially in near-miss scenarios. The technique is
applicable not only to laboratory medicine but also to other healthcare-associated disciplines.
A. Provide a summary of the following aspects of a root cause analysis related to the sentinel
event found in the attached Accreditation Audit Case Study – Task 2 Specific artifacts by doing
1. Describe the sentinel event.
2. Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event.
3. Discuss the barriers that may impede effective interaction among the personnel present during
the sentinel event.
a. Propose ways to improve interactions among the personnel present.
4. Discuss a quality improvement tool to be used to conduct the root cause analysis.
B. Outline a corrective action plan to ensure that the sentinel event does not recur by doing the
1. Recommend a risk management program or process change to ensure that the sentinel event
does not recur.
a. Discuss resources available to support these changes.
C. When you use sources, include all in-text citations and references in APA format.
Note: When bulleted points are present in the task prompt, the level of detail or support called for
in the rubric refers to those bulleted points.
Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link
included in the Evaluation Procedures section.
Note: When using sources to support ideas and elements in a paper or project, the submission
MUST include APA formatted in-text citations with a corresponding reference list for any direct
quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not
been quoted or paraphrased in the text of the paper or project.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely
paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.
Accreditation Audit Case Study – General Artifacts link opens in new window
1. Accreditation Audit Case Study – Task 2 Artifacts link opens in new window