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Commentary
Sentinel events, serious reportable events, and root cause analysis.
March 25, 2015
Chen TC, Schein OD, Miller JW. JAMA Ophthalmol. 2015;133(6):631-632.
This commentary describes the importance of performing root cause analyses following sentinel events and never events in order to identify factors that contribute to failure and develop solutions to reduce risks. The authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis following a never event, along with recommendations for organizations to consider to determine improvement strategies.
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