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Run: Sentinel Event Root Cause Analysis

Sentinel Event Root Cause Analysis template for documenting the event, timeline, proximate cause, root cause, and corrective actions after a serious patient ...

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Event Overview

Event date and time documented critical (required)

Note (optional)

Event type and location identified critical (required)

Patient, resident, or affected person identifier recorded in approved internal format critical (required)

Immediate harm level or outcome documented critical (required)

Note (optional)

Initial notification chain documented

Event Sequence and Timeline

Chronological timeline completed from pre-event to outcome critical (required)

Key handoffs and communication points identified

Delays, omissions, or deviations from expected process identified critical (required)

Relevant records, logs, and witness statements reviewed critical (required)

Yes No N/A

Note (optional)

Timeline verified against source documentation critical (required)

Yes No N/A

Proximate Cause Analysis

Proximate cause clearly stated critical (required)

Direct failure mode identified critical (required)

Evidence supports proximate cause conclusion critical (required)

Yes No N/A

Alternative immediate causes considered and ruled out

Root Cause and Contributing Factors

Root cause statement identifies a system or process failure critical (required)

Contributing factors documented

Latent system issues identified critical (required)

Policy, training, staffing, and equipment contributors assessed

Yes No N/A

Note (optional)

Root cause supported by evidence and not assigned to individual blame alone critical (required)

Yes No N/A

Corrective Actions and Follow-Up

Corrective actions are specific and measurable critical (required)

Action owner assigned critical (required)

Due date assigned for each corrective action critical (required)

Note (optional)

Effectiveness monitoring method defined critical (required)

Escalation or risk mitigation implemented for immediate hazards critical (required)

Yes No N/A

Documentation and Approval

RCA report reviewed for completeness critical (required)

Yes No N/A

Approver signature captured critical (required)

Note (optional)

Record retention and distribution completed per policy

Yes No N/A

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