RCA is a structured study that determines the underlying causes of adverse events. RCA focuses on systems, processes, and common causes that were involved in the adverse event. It then determines ways to prevent recurrence by identifying potential improvements in systems and processes that should decrease the likelihood of repeating the event.
Occurrences that may jeopardize patient safety must be investigated immediately, and appropriate risk-reduction activities must be implemented. The most serious of these occurrences has been labeled by the Joint Commission as a sentinel event. A sentinel event is an unexpected event involving patient death or serious physical or psychological injury. A root cause analysis must be performed if a sentinel event occurs.
Another serious event that also requires investigation at the level of a root cause analysis is sometimes referred to as a near miss. A near miss is a process variation that did not result in patient death or serious injury, but a significant risk of one of these adverse outcomes was present and could occur if the same process variation was repeated.