Root Cause Analysis
Note About RCA Sentinel Event
The RCA case study was modified from a sentinel event reported in the following article: Smetzer, J., Baker, C., Byrne, F. D., & Cohen, M. R. (2010). Shaping systems for better behavioral choices: Lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety, 36(4), 152-163.
Short videos are used in this non-linear module to introduce students to the case, and to give them the opportunity to view interactions between the key players.