An RCA is the main tool used by hospitals when investigating the cause of an error in healthcare. The Joint Commission requires a root cause analysis to be performed on every sentinel event like the one experienced by Mr. B in the given scenario. A sentinel event is an adverse event in health care delivery or other service, which either leads to or has potential to lead to catastrophic outcomes (for example, near miss), thereby often mandating initiation of emergency intervention or of preventive measures (Sentinel event, 2003-2015). The Joint Commission defines a root cause analysis as a process used to identify the factors that influence fluctuation in performance, as well as the occurrence or possible occurrence of a sentinel event. A
