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Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Se
All levels
U.S. Standards

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events, 7th Edition

Provides and explains The Joint Commission’s framework for conducting a root cause analysis and how to implement corrective actions.

Release Date: May 15, 2020. Approximately 175 pages. 

  • An individual license is intended for single users only. This ebook cannot be shared, disseminated, downloaded, or posted for widespread or public use. 
  • site license allows this ebook to be shared among unlimited users but only within one facility or site, either by posting to a secure intranet site or by providing other means of secure access. 
  • system license allows this ebook to be shared among unlimited users within all facilities or sites within a health care system, either by posting to a secure intranet site or by providing other means of secure access. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.

$119.00 - $279.00
Product Description

Product Description

According to World Health Organization statistics, adverse events in health care affect 1 in 300 patients, resulting in tragedy for patients and their families and taxing an already overburdened health care system. To address and prevent reoccurrences of such errors, The Joint Commission’s Sentinel Event Policy requires accredited health care organizations to identify and examine the system failures or defects that contributed to the adverse or sentinel event. Root cause analysis (RCA) provides a systematic approach to identifying these contributing factors. And in the interest of identifying potential safety problems before they occur, proactive risk assessment, of which one type is failure mode and effects analysis (FMEA), uses a prospective approach to improve the likelihood of favorable outcomes and to prevent harm to patients. 
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events will take readers step by step through the process of conducting RCA in their organizations. It will also offer strategies and suggestions for implementing FMEA. Featuring a newly streamlined, approachable design, this 7th edition of our best-selling Root Cause Analysis in Health Care will guide health care organizations through the Joint Commission requirements, outlining steps to prevent sentinel events such as medication errors, patient suicide, wrong-site surgery, patient elopement, and more. Refreshed tools and examples will help organizations collect the data they need and demonstrate how to use that data to learn from previous experience. 
Key Topics
  • Overview of root cause analysis and how it is used as a response to a sentinel event
  • Overview of proactive risk assessment and how it is used to prevent process and product problems before they occur
  • Addressing sentinel events and adverse events in policy and practice
  • Preparing for a root cause analysis
  • Conducting root cause analysis
  • Determining proximate and root causes
  • Designing and implementing a corrective action plan for improvement
Key Features
  • A comprehensive four-phase root cause analysis framework that links to The Joint Commission’s 21-Step Framework for a Root Cause Analysis
  • Downloadable and adaptable checklists and worksheets for applying the framework 
  • Tools to Try (many of which are downloadable and adaptable) that help users implement root cause analysis in their organizations
  • A downloadable and editable version of The Joint Commission’s Framework for a Root Cause Analysis and Corrective Action Plan
  • Information about FMEA
Standards: Leadership, Performance Improvement
Setting: Ambulatory Care, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Office-Based Surgery, Nursing Care Centers, Laboratory
Key Audience: Risk managers, quality improvement staff, patient safety officers, compliance managers, accreditation professionals, staff educators, and health care executives and administrators across health care settings
Table of Contents

Table of Contents

Chapter 1—Root Cause Analysis: An Overview
Investigating Patient Safety Events: The Need for Comprehensive Systematic Analysis
RCA2  in High Reliability Industries
When Can a Root Cause Analysis Be Performed?
Variation and the Difference Between Proximate and Root Causes
Benefits of Root Cause Analysis
Maximizing the Value of Root Cause Analysis
The Root Cause Analysis and Corrective Action Plan: Doing It Right
Chapter 1—Tools to Try
Root Cause Analysis Evaluation Checklist 
WWW Template 
Checklist for Conducting a Root Cause Analysis and Implementing a Corrective Action Plan
Chapter 2—Addressing Sentinel Events in Policy and Strategy
The Range of Adverse Events in Health Care
Signals of Risk: Close Calls and No Harm Events
The Joint Commission’s Sentinel Event Policy
Reasons for Reporting a Sentinel Event to The Joint Commission
Required Response to a Sentinel Event
Joint Commission International’s Sentinel Event Policy
Related Joint Commission International Standards
Developing Your Own Sentinel Event Policy
Leadership, Culture, and Patient Safety Events
Early Response Strategies
Event Investigation
Onward with Root Cause Analysis
Chapter 2—Tools to Try
Optional Sentinel Event Policy Evaluation Checklist 
Incident Tracking Form 
Sentinel Event Communications Alert 
Disclosure Checklist
RCA Training Checklist
Chapter 3—Preparing for Root Cause Analysis
Step 1—Organize a Team
Step 2—Define the Problem
Step 3—Study the Problem
Chapter 3—Tools to Try
Tracking Key Steps in Root Cause Analysis 
Types of Open-Ended Questions
Checklist: Leadership Techniques for Promoting High-Quality Group Discussion
Chapter 4—Determining Proximate Causes
Step 4—Determine What Happened
Step 5—Identify Contributing Process Factors
Step 6—Identify Other Contributing Factors
Step 7—Measure—Collect and Assess Data on Proximate and Underlying Causes
Chapter 4—Tools to Try
Root Causes Checklist
Five Whys Root Cause Analysis Template *New content
Data Collection Evaluation Checklist 
Change Analysis Worksheet
Chapter 5—Identifying Root Causes
Step 9—Identify Which Systems Are Involved—The Root Causes
Step 10—Prune the List of Root Causes
Step 11—Confirm Root Causes and Consider Their Interrelationships
Chapter 5—Tools to Try
Probing Questions for Root Cause Analysis
Problematic Systems or Processes Checklist 
Evaluation Checklist for Differentiating Root and Contributing Causes
Chapter 6—Designing and Implementing a Corrective Action Plan for Improvement
Step 12 Explore and Identify Risk-Reduction Strategies
Step 13 Formulate Improvement Actions
Step 14 Evaluate Proposed Improvement Actions
Step 15 Design Improvements
Step 16 Ensure Acceptability of the Corrective Action Plan
Step 17 Implement the Improvement Plan
Step 18 Develop Measures of Effectiveness and Ensure Their Success
Step 19 Evaluate Implementation of Improvement Efforts
Step 20 Take Additional Action
Step 21 Communicate the Results
Chapter 6—Tools to Try
Checklist for Integrating the Improvement Plan 
Communication Plan Template 
Change Management Template
Failure Mode and Effects Analysis
Operational Definition
Appendix—Framework for Root Cause Analysis and Corrective Actions


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Conflict of Interest

Joint Commission Resources maintains control over all continuing education content provided to ensure content integrity and minimize educational bias. All education planners, faculty, content reviewers, authors, and others involved with continuing education activities disclose influencing relationships, or lack thereof, including financial or commercial interests. The Joint Commission ensures the accuracy and consistency of the application of accreditation criteria to ensure appropriateness of relationships and affiliations that may impact educational content.

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