According to Health Care Risk Management standards supported by ASHRM and the American Hospital Association Certification Center, The Joint Commission’s sentinel event policy requires organizations to complete a thorough root cause analysis and develop an action plan within 45 days of becoming aware of the sentinel event.
The root cause analysis must identify underlying system failures and contributing factors rather than focusing solely on individual performance. The resulting action plan must outline specific corrective measures, assign responsibility, establish implementation timelines, and include mechanisms to monitor effectiveness. The emphasis is on sustainable system improvement to reduce the likelihood of recurrence.
Failure to complete the analysis and action plan within the required timeframe may result in additional review, accreditation consequences, or other follow-up actions by The Joint Commission. Timely completion demonstrates organizational accountability, leadership oversight, and commitment to patient safety.
Clinical and patient safety objectives emphasize structured investigation processes, documentation of corrective actions, and alignment with accreditation standards. Therefore, the required timeframe for completion of the root cause analysis and action plan following awareness of a sentinel event is 45 days.
