A. Conduct a root cause analysis of the sentinel event found in the attached Accreditation Audit Case Study - Task 2 Artifacts by doing the following:
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 following:
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.