What is root cause analysis used for in patient safety?

• A. To identify underlying system factors contributing to an error and implement changes to prevent recurrence.
• B. To assign blame to an individual clinician for the error.
• C. To document the incident for regulatory reporting only.
• D. To increase the severity of consequences for staff.

Answer: (A)

Root cause analysis focuses on understanding why an adverse event happened by looking beyond the individual who made a mistake to the conditions that allowed it to occur. The aim is to uncover underlying system factors—design flaws, workflow gaps, communication failures, policies, training, equipment, or environmental issues—and then implement changes that reduce the chance of recurrence. This approach supports a just culture, emphasizing system improvement over blaming people.

In practice, RCA involves gathering data, outlining the sequence of events, identifying contributing factors, and determining the root causes. Then teams plan corrective actions—such as redesigning processes, adding checklists, standardizing procedures, implementing safety barriers, and improving communication and supervision—and follow up to assess whether those changes actually prevent future harm. It’s not about assigning blame to a clinician, nor merely documenting the incident for regulators, nor increasing penalties for staff; it’s about making systemic changes to prevent harm.