If something goes seriously wrong with a patient in your organization's care, you want to know what happened and why so that it won't happen again to anyone else. A fully updated version of a Joint Commission Resources best-seller, Root Cause Analysis, Fourth Edition is designed to help health care organizations around the world prevent system failures by using the technique of root cause analysis to identify causes of sentinel events, implement risk reduction strategies, and develop effective and efficient ways to improve processes. This book offers a straightforward, 21-step framework for conducting a root cause analysis. The fourth edition also includes a CD-ROM containing root cause analysis tools such as worksheets, a slide presentation, sample case studies, and relevant articles compiled from Joint Commission Resources periodicals. ??This product is also offered as a PDF book.