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Root cause analysis (RCA) is an error analysis tool used in health care to investigate serious adverse events. TJC has mandated the use of RCAs to analyze sentinel events since 1997. RCAs identify underlying problems that increase the likelihood of errors rather than focusing on mistakes made by individuals. An RCA uses a systems approach to identify both active and latent errors. The goal of an RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events.

RCAs begin with data collection and reconstruction of the event through record review and participant interviews. An interprofessional team then analyzes the sequence of events leading to the error, with two main goals: identify how the event occurred through identification of active errors; and identify why the event occurred through systematic identification and analysis of latent errors (AHRQ, 2018a, 2018b). Action plans are developed, implemented, and evaluated based on RCA findings.

Nurse leaders striving for high reliability must facilitate RCA investigations into how and why errors occur. These investigations make errors visible, encourage learning from events, and help prevent errors in the future. Direct care nurse involvement in RCAs is critical to their success. As part of the RCA investigation, nurses need to be comfortable while recounting the actions they took and the rationale for their actions. In addition, direct care nurses are crucial for the development of action plans to help mitigate future risk.