NCLEX-RN — US Licensure Track › 1a. Management of Care
Quality Improvement & Sentinel Events
A sentinel event is an unexpected occurrence involving death or serious physical/psychological harm unrelated to the natural course of the patient's illness — wrong-site surgery, a retained surgical item, or a suicide in a staffed care setting are classic examples. These trigger a root cause analysis (RCA), a structured, blame-free process focused on identifying systemic contributing factors rather than individual fault, because most errors trace back to process gaps, not a single person's carelessness.
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