What is the primary purpose of a root cause analysis after an adverse event?

• A. Document for legal purposes
• B. Assign blame to staff
• C. Identify underlying causes to prevent recurrence
• D. Improve patient satisfaction scores

Answer: (C)

Root cause analysis after an adverse event is about uncovering deeper factors in the system that allowed the event to occur, so you can prevent it from happening again. It looks beyond what happened on the surface and asks why the sequence of events happened, often uncovering gaps in processes, communication, equipment, training, or policies. By identifying these underlying causes, the focus is on implementing changes that reduce risk, such as policy updates, process redesign, staff education, or system changes, to avert future harm and improve overall safety.

This isn’t about assigning blame to individuals or simply documenting the incident for legal purposes. It isn’t primarily aimed at boosting patient satisfaction scores, though safer care can contribute to better satisfaction over time. The goal is to find the root factors and put corrective actions in place to prevent recurrence.