After a sentinel event, a root cause analysis (RCA) is performed.

RCA identifies system factors (C), such as process or communication flaws, causing a sentinel event to prevent recurrence. Retraining (A) and process redesign (B) are potential outcomes, not RCA components. Reporting to accrediting bodies (D) follows RCA. NAHQ emphasizes system factor identification in RCA.

NAHQ CPHQ Study Guide, Patient Safety Section, “Root Cause Analysis for Sentinel Events”; NAHQ CPHQ Practice Exam, Patient Safety Processes.