July 24, 2007 | Mark Paradies

Missouri Senate Considers a Sentinel Event and Root Cause Analysis Law for Hospitals

Another state is considering their own law to improve patient safety and reduce preventable sentinel events. The Missouri Senate is considering a bill that requires incident reporting within 24 hours of the incident and root cause analysis within 20 days.

The bill defines root cause analysis as:

(6) “Root cause analysis”, a structured process for identifying
79 basic or causal factors that underlie variation in performance,
80 including but not limited to the occurrence or possible occurrence of
81 a reportable incident. A root cause analysis focuses primarily on
82 systems and process rather than individual performance and
83 progresses from special causes in clinical processes to common causes
84 in organizational processes and identifies potential improvements in
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processes or systems that would tend to decrease the likelihood of such
86 events in the future, or determines after analysis that no such
87 improvement opportunities exist.

To read the bill, see:


For the legislative status of the bill, see:


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