Sentinel Events – The Problem With Only Focusing on the Direct Cause

School safety recommendations that have come out following the Sandy Hook Elementary School shooting are revealing a positive trend to look beyond the direct causes for sentinel events.  I’ve often felt that an emphasis on direct causes results in excessive fortification of schools and layers of procedures.  The journey to the root cause is longer, convoluted and can surface societal issues that seemingly are without remedies – one being the overwhelming need for mental health services for youth.   

“When a sentinel event occurs in a hospital, most employees are focused on the direct causes that have led to the event.  For example, many will claim that the cause of a medication error is a failure to check the label against the patient’s wristband.  But this is a direct cause.  To get the real reason, one should ask why the clinician did not check the label against the wristband (Alemi, Vang, Laskey, p. 169).” 

If a student is involved in a fight at school, the direct cause of the fight might be that the student was bullied and became upset.  However, the root cause might be that the school lacked an effective process for students to report bullying to adults.

When conducting an investigation into an incident of school violence, seek to identify both the direct cause and the root cause.  Addressing the root cause will be the proactive measure to decreasing the likelihood of a sentinel event. 

Alemi, Vang, Laskey (2007).  Decision Analysis for Healthcare Managers.  p. 169