Sentinel Event Root Cause Analysis

Structured inspection template for conducting a Joint Commission sentinel event root cause analysis, including event sequence, proximate cause, root cause, contributing factors, and corrective actions.

Event Overview

• Event date and time documented
• Event type and location identified
• Patient, resident, or affected person identifier recorded in approved internal format
• Immediate harm level or outcome documented
• Initial notification chain documented

Event Sequence and Timeline

• Chronological timeline completed from pre-event to outcome
• Key handoffs and communication points identified
• Delays, omissions, or deviations from expected process identified
• Relevant records, logs, and witness statements reviewed
• Timeline verified against source documentation

Proximate Cause Analysis

• Proximate cause clearly stated
• Direct failure mode identified
• Evidence supports proximate cause conclusion
• Alternative immediate causes considered and ruled out

Root Cause and Contributing Factors

• Root cause statement identifies a system or process failure
• Contributing factors documented
• Latent system issues identified
• Policy, training, staffing, and equipment contributors assessed
• Root cause supported by evidence and not assigned to individual blame alone

Corrective Actions and Follow-Up

• Corrective actions are specific and measurable
• Action owner assigned
• Due date assigned for each corrective action
• Effectiveness monitoring method defined
• Escalation or risk mitigation implemented for immediate hazards

Documentation and Approval

• RCA report reviewed for completeness
• Approver signature captured
• Record retention and distribution completed per policy