According to Health Care Risk Management standards supported by ASHRM and the American Hospital Association Certification Center, The Joint Commission’s sentinel event process requires completion of a thorough root cause analysis and development of a corrective action plan. While various analytical tools such as fishbone diagrams, flowcharts, or Pareto charts may be used to assist in identifying contributing factors, these specific tools are not mandated.

The essential required component is a written action plan that identifies specific improvement steps, assigns responsibility, and includes measurable outcomes and timelines for implementation. The action plan must address root causes and system vulnerabilities, not merely individual performance issues. It should demonstrate how corrective actions will reduce the likelihood of recurrence and include monitoring mechanisms to evaluate effectiveness.

Fishbone diagrams and Pareto charts are optional tools used during analysis but are not explicitly required elements. Similarly, departmental flowcharts may support understanding of processes but are not mandated by The Joint Commission.

Clinical and patient safety objectives emphasize systematic investigation, leadership oversight, and documented improvement efforts following sentinel events. Therefore, a detailed action plan with implementation dates is the required analysis component within the sentinel event process.