Root cause analyses, or RCAs, are performed by interdisciplinary teams involving everyone who is closest to the incident, and they focus primarily on systems and processes rather than individual performance. RCAs involve a series of “why” questions aimed at identifying and eliminating each contributing cause, drawing from data, interviews and literature reviews. The Joint Commission requires accredited hospitals to perform a RCA or other “comprehensive systematic analysis” following a sentinel event—a patient safety incident that results in death or serious injury. The Joint Commission also states that it expects organizations to use its analysis to come up with a corrective action plan within 45 business days of becoming aware of a sentinel event.
