What approach should be used when investigating sentinel events?

• A. Blaming individuals
• B. No formal investigation
• C. Root cause analysis and action plans with monitoring
• D. Immediate punitive measures

Answer: (C)

When investigating sentinel events, the focus is on learning from failures by examining systems, processes, and interactions rather than blaming people. The approach most aligned with this goal uses a structured root cause analysis to uncover underlying factors that contributed to the event. From there, the team develops concrete action plans that specify what changes are needed, who is responsible, and when they should be completed. Crucially, these plans include metrics and follow-up to monitor whether the changes actually reduce risk and prevent recurrence. This non-punitive, system-oriented path promotes transparency, shared learning, and continuous improvement.

Blaming individuals tends to drive fear and underreporting, and avoids addressing the broader system issues. Not conducting a formal investigation misses vital information about how processes failed. Immediate punitive measures focus on discipline rather than preventing future harm and can undermine reporting and improvement efforts.