When has the cause analysis reached the root?

Until a few years ago, the triennial JCAHO survey only peripherally involved the risk manager. With the advent of the sentinel event policy, this will certainly change regardless of whether the organization chooses to self-report. It is anticipated that the risk manager will be involved with the triennial survey particularly with regards to the PI standards. The mechanisms used by the organization to manage sentinel events will be scored within these standards and will be examined as part of the survey whether or not an event has occurred. The goal of ensuring that errors are managed in a manner that corrects the most fundamental contributing causes lies within the role of the risk manager.