Q1. What does it cost to do a Root Cause Analysis?

Q2. Of the four options offered by the JCAHO for review of an root cause analysis after a sentinel event, which do you recommend?

Q3. Is the "voluntary self-reporting" that JCAHO talks about really voluntary?

Q4. Is this root cause analysis just another make-work, JCAHO requirement?

Q5. What is the difference between a proximal cause and a root cause, and why have you said that you dislike both terms?

Q6. When should a facility perform a root cause analysis on an event not required by JCAHO?

Q7. You seem to frequently use the term "adverse event or condition" rather than "sentinel event." Why?

Q8. What are the comments and responses you've heard in regard to JCAHO's Sentinel Event and Root Cause Analysis Policy?

Q9. What do you make of the relative preponderance of suicides among the recently released data about reported sentinel events (Of 562 sentinel events reviewed by JCAHO from 1/95 through 7/99, 117 were patient suicides)?

Q10. Once a root cause analysis is done, who should be responsible for making certain that any recommended changes are implemented?

Q11. Who determines whether or not your root cause analysis is adequate?

Q12. Can you recommend any software to help with a root cause analysis?

Q13. What constitutes a "thorough and credible" root cause analysis?

Q14. What are the reporting requirements regarding sentinel events and root cause analysis for Department of Defense healthcare facilities

Q15. Why the emphasis on a review of the literature as part of a root cause analysis?

Q16. What do you see as the relationship between root cause analysis and peer review?

Q17. I'm the risk manager at a medium-sized community hospital, with the usual limited resources. Would you recommend going to workshops and the like to learn how to do an effective root cause analysis?