PTCB 26-27: Sentinel Events & RCA

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Last updated 12:57 AM on 7/7/26

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sentinel event

causes death, permanent harm, or sever temporary harm

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self-harm, suicide, workplace violence, delayed treatment

examples of sentinel events

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RCA

method to investigate serious medical errors and system failures

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cause and effect diagrams, 5 Why’s

RCA tools

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system-level imporvement

RCA emphasis