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Getting to the Roots of the Problem

Created Apr 27 2018, 11:09 AM by Lippincott Solutions
  • sentinel events
  • medical errors
  • patient safety
  • The Joint Commission

For more than 2 decades, The Joint Commission (TJC) has required root cause analysis of hospital sentinel events. The thinking is, if we want to avoid sentinel events, we need to understand the sequence of occurrences that paved the way for these tragic events to happen.

Root cause analysis allows for a systems approach to investigate serious adverse events (say, a medication error or surgical mistake) without assigning full blame to one person (say, Jenna or Dave). Instead, the idea is to identify hidden organizational problems that can be addressed to keep future patients from unnecessary harm.


According to the Agency for Healthcare Research and Quality’s Patient Safety Network, root cause analyses should follow a prespecified protocol.

Steps generally include:

  1. Reviewing records and conducting participant interviews to reconstruct the event.
  2. Analysis of circumstances that led to the event (by a multidisciplinary team for a broad perspective). The analysis includes pointing out both active errors (mistakes that happened “at the point of interface between humans and a complex system,” the Patient Safety Network explained) and latent errors (stumbling blocks within an organization that contributed to the error).

Latent errors span from work environment problems (lack of equipment), to organizational/management problems (a physician discouraging a nurse from reporting a drug error) to staffing issues (understaffed units), and more.


The Patient Safety Network compared traditional analysis to root cause analysis in this way. Consider a situation in which the wrong patient undergoes a cardiac procedure.

Traditional analysis puts the blame on Jenna (or Dave), the nurse who sent the patient for the procedure despite the absence of a consent form.

“However, the subsequent root cause analysis revealed 17 distinct errors ranging from organizational factors [the cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather than by medical record number] to work environment factors [a neurosurgery resident who suspected the mistake did not challenge the cardiologists because the procedure was at a technically delicate juncture],” the Patient Safety Network reported.

As a result of the broader, more comprehensive root cause analysis, the hospital was able to put in place a number of changes to lessen the chance of a similar event going forward. And Dave (or Jenna) got a more balanced consideration of their contribution to the incident.


Real change is essential to the success of root cause analysis. Some critics of root cause analysis efforts say they ultimately fail, though, because of factors such as facilities’ overreliance on solutions that prove weak, like “better education” and enforcing policies already on the books.

The Patient Safety Network explained that the National Patient Safety Foundation suggested changing the name of root cause analysis to “root cause analysis and action” to ensure findings lead to true, lasting organizational improvement.

As the Patient Safety Network explained, “The ultimate goal of root cause analysis, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events.”