Critique the assigned sentinel event case. Use risk management principles (e.g.

Critique the assigned sentinel event case.
Use risk management principles (e.g., Root cause analysis, 5 whys) to discuss the sentinel event and identify the causes of the event.
Using a quality improvement methodology and clinical risk management framework (e.g., PDSA, Six Sigma etc), provide two recommendations on how the catastrophic outcome may have been circumvented.
Consider you are writing this report to your manager, safety committee, director etc. to support a change in practice as part of a Root cause analysis of a sentinel event.
Determine if the practice identified in the case study is current and follows best practice guidelines (both NSQHS, RN Standards for Practice and any Facility Clinical Practice Guidelines e.g., RPH, SCGH, WACHS).
Ensure you include evidence to support your recommendations of any change or clinical improvement processes
A minimum of 16 quality references is required.