Summary C489 Organizational Systems and Quality Leadership SAT Task 2

Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis In 1996, the Joint Commission adopted a sentinel event policy which requires accredited organizations to perform a Root Cause Analysis (RCA) after a sentinel event occurs. An RCA is a systematic approach used to analyze serious adverse events and to identify both active and latent errors. The general purpose of conducting an RCA is to identify the cause of a serious event by looking the sequence of events that lead to the error and prevent future occurrences of the event by establishing a process to prevent the errors that lead up to the sentinel event (PSNet, 2019). This process takes the blame off an individual and looks at system barriers that contributed