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HC405 Business Finance

Published : 02-Sep,2021  |  Views : 10


Identify the components of risk management, incident reports and sentinel reporting
Identify how sentinel events can point to opportunities to improve safety in healthcare organizations.



This is a report, which depicts the root cause analysis of a health care organization where a sentinel event has occurred. The cause and effect fishbone diagram has been used to identify the causes for this incident.  The analyses of severe incident in done through a structured method, which is known as the root cause analysis.  Root cause analysis is a tool for the analysis of the error and it helps to identify the fundamental problems in an organization. The root cause analysis is an effective method of the identification of errors done by the individuals in an organization. The root cause analysis not only identifies the active errors in an organization but also at the same time identifies the hidden errors within an organization. Root cause analysis collects all the relevant data and constructs it into effective way by conducting interviews and reviewing the existing records.

Fishbone Analysis

Fishbone analysis is one of the methods, which is used in quality management to identify the main causes for occurrence of an event (Izudi et al., 2017). The diagram portrays the causes and the effects of a problem; this can be considered as a tool for visualization and can be used to identify the major factors. This diagram is also known as Ishikawa diagram (Jingxia et al., 2014).

The above fishbone analysis shows the exact causes that has caused the death of the patient. The community hospital wing specialises in the delivery of women and the doctor made an error of judgement (Latino, Latino & Latino, 2016). She already had the idea that operation theatre was in the third floor the hospital and it will take more time than the expected to reach there. The staffs were aware of the fact that the lift will take more time and the condition of the patient may deteriorate within that time period. There should have been better communication among the staffs; the lack of communication between them caused them to take more time than the expected to reach the operation wing (Abdi & Ravaghi, 2017). There are certain cases where emergency equipments are required but there are no availability of equipments for the contingencies.


  Thus, after the evaluation of the fishbone analysis the report is able to identify the various causes, which has lead to the sentinel incident. The death of a patient is a serious issue and so it is necessary for the hospital authorities to identify the causes for the incident so that the hospital can prevent further events like this.  This analysis will help the organization to prevent such incidents in the future and help in better structuring of the organization.  There are various hidden issues that have not been identified earlier and with the help of the root cause analysis, the hidden issues have been magnified.


Abdi, Z., & Ravaghi, H. (2017). Implementing root cause analysis in Iranian hospitals: challenges and benefits. The International journal of health planning and management, 32(2), 147-162.

Izudi, J., Epidu, C., Katawera, A., & Kekitiinwa, A. (2017). Quality Improvement Interventions for Nutritional Assessment among Pregnant Mothers in Northeastern Uganda. BioMed Research International, 2017.

Jingxia, L., Huani, P., Dan, L., & Li, G. (2014). Fishbone diagram reduces the incidence of blood residual after sealing tube indwelling needle. Modern Clinical Nursing, 9, 020.

Latino, R. J., Latino, K. C., & Latino, M. A. (2016). Root cause analysis: improving performance for bottom-line results. CRC press.

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