What is a root cause analysis and when should it be used after a sentinel event?

• A. Root cause analysis identifies underlying causes of an event; use after a sentinel event to prevent recurrence by addressing systemic factors
• B. Random event analysis after any incident
• C. Risk assessment to evaluate future hazards only
• D. Root cause analysis is used to assign blame to individuals

Answer: (A)

Root cause analysis is a systematic process for uncovering the underlying factors that lead to a sentinel event, with the aim of preventing recurrence by addressing weaknesses in the system rather than assigning blame to individuals. After a sentinel event, RCA investigates what happened, why it happened, and how organizational systems—such as processes, policies, communication, equipment, training, and culture—allowed it to occur. The focus is on identifying root causes and contributing factors, then designing corrective actions that make systemic improvements and include follow-up to ensure effectiveness.

This approach contrasts with analyzing random occurrences or only assessing future hazards, and it avoids blaming individuals. By drilling down beyond surface events to the systemic conditions that permitted the incident, RCA guides changes that reduce the chance of recurrence and improve overall safety.