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Root cause analysis, Patient safety, Sentinel events, Surgery



  1. Dattilo, Elaine RN
  2. Constantino, Rose E. PhD, JD, RN, FAAN, FACFE


The most fundamental reason for the failure or inefficiency of a process, in any work setting, is referred to as a root cause. Root cause analysis is the process of learning from consequences wherein healthcare providers take a step back and gain knowledge from near-misses, adverse events, or sentinel events in the operating room and all areas of healthcare. This article discusses root cause analysis and nursing management responsibilities as they relate to wrong-site surgery.