The Joint Commission on Accreditation of Healthcare Organizations has started requiring investigations for all sentinel occasions. These investigations can be of colossal value. They catch both the comprehensive view point of the incident and the subtle elements. They encourage framework assessment, examination of restorative activity (Williams, 2001). We must utilize a multi-disciplinary group approach, known as Root Cause Analysis – RCA – to study of human services related to sentinel occasions and close calls. The objective of the RCA procedure is to discover what happened, why it happened, and how to keep it from happening once more. Since our culture of safety depends on counteractive action, not discipline, RCA groups examine how well patient care works in hospital settings. We concentrate on the “how” and the “why”? not on the “who”. The RCA procedure is an apparatus for recognizing prevention methodologies. It is a procedure that is a piece of the push to manufacture a society of security and move past the way finger pointing (U.S. Department of Veterans Affairs, 2015).
The primary danger recognized is the quantity and skill of medical staffing the emergency room. As the quantity of patients expanded, it ought to have been obvious that was not enough staff to look after the patients. The emergency department ought to be viewed as a high priority location, and should have staffed with more Registered Nurses; LPNs essentially do not have the training and abilities to assess patients or delegate the workload…………………….
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