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PSNet: Patient Safety Network
Book/Report

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

Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.

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