Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

Root cause analysis has been widely adopted as a strategy to investigate events, despite questions regarding its effectiveness in health care. This revised publication provides information about updated approaches to root cause analysis with an emphasis on identification of causal and contributing factors. It highlights the use of failure mode and effects analysis as a complementary sentinel event examination strategy that enables design of proactive and reactive improvements.